A Survey of Clinicians Working in Brain Injury Rehabilitation: Are Social Cognition Impairments on the Radar?

OBJECTIVES: To examine the social cognition assessment practices of clinicians working with children and adults with traumatic brain injury. MAIN MEASURES: Online survey addressing frequency of social cognition impairments, how these are assessed and obstacles to same, and treatment practices. PARTICIPANTS: A total of 443 clinicians worldwide working in inpatient and outpatient settings. RESULTS: While 84% of clinicians reported that more than half of their clients with severe traumatic brain injury had social cognition impairments, 78% of these reported that they infrequently or never assessed these domains using a formal assessment tool. Lack of reliable tests was most frequently (33% of respondents) cited as the greatest barrier to undertaking social cognition assessment. CONCLUSIONS AND IMPLICATIONS: Improvements are needed in the development and norming of instruments capable of detecting social cognition impairments in the traumatic brain injury population. Additional training and education is needed in the use of social cognition assessment tools.

Blast overpressure induces shear-related injuries in the brain of rats exposed to a mild traumatic brain injury.

BACKGROUND: Blast-related traumatic brain injury (TBI) has been a significant cause of injury in the military operations of Iraq and Afghanistan, affecting as many as 10-20% of returning veterans. However, how blast waves affect the brain is poorly understood. To understand their effects, we analyzed the brains of rats exposed to single or multiple (three) 74.5 kPa blast exposures, conditions that mimic a mild TBI. RESULTS: Rats were sacrificed 24 hours or between 4 and 10 months after exposure. Intraventricular hemorrhages were commonly observed after 24 hrs. A screen for neuropathology did not reveal any generalized histopathology. However, focal lesions resembling rips or tears in the tissue were found in many brains. These lesions disrupted cortical organization resulting in some cases in unusual tissue realignments. The lesions frequently appeared to follow the lines of penetrating cortical vessels and microhemorrhages were found within some but not most acute lesions. CONCLUSIONS: These lesions likely represent a type of shear injury that is unique to blast trauma. The observation that lesions often appeared to follow penetrating cortical vessels suggests a vascular mechanism of injury and that blood vessels may represent the fault lines along which the most damaging effect of the blast pressure is transmitted.

Long-term sequelae after acquired pediatric hemorrhagic cerebellar lesions.

PURPOSE: The aim of the present study was to assess cognitive, affective, and motor long-term sequelae after acquired focal pediatric cerebellar lesions. METHODS: Eight patients with a history of isolated acquired hemorrhagic cerebellar lesions before the age of 13 participated in this study. All participants underwent a neurologic examination, including the Zurich Neuromotor Assessment (ZNA) and the International Cooperative Ataxia Rating Scale (ICARS). Cognitive functions have been evaluated with a general cognitive assessment and an extensive neuropsychological battery. Furthermore, patients and parents filled in questionnaires about quality of life and possible behavioral or emotional problems. RESULTS: The results revealed that all patients exhibited motor problems (ZNA). Most participants had further restricted oculomotor movements (ICARS). Age at injury and the full scale IQ were significantly positively correlated (Pearson correlation 0.779; p = 0.023). Conversely, no overall neuropsychological profile could be identified except for marginally reduced reaction times and susceptibility to interference. In addition, borderline results in semantic and phonemic word fluency tasks were apparent. A dysexecutive syndrome was diagnosed in one patient. However, verbal performance and reading abilities were non-pathologic in all participants. The patients reported having a good quality of life without major physical restrictions. CONCLUSIONS: Emotional disturbances and the presence of a mild cerebellar cognitive affective syndrome (as frequently described in adult patients) could only be confirmed in adolescents with vermis lesions. Nevertheless, in laboratory conditions, neuropsychological impairments were present in all patients. Heterogeneity of age at injury and exact lesion site may have led to interpersonal differences in neuropsychological outcome.

Lateralized cerebellar contributions to word generation: a phonemic and semantic fluency study.

Impairment on verbal fluency tasks has been one of the more consistently reported neuropsychological findings after cerebellar lesions, but it has not been uniformly observed and the possible underlying cognitive basis has not been investigated. We tested twenty-two patients with chronic, unilateral cerebellar lesions (12 Left, 10 Right) and thirty controls on phonemic and semantic fluency tasks. We measured total words produced, words produced in the initial 15 seconds, errors and strategy switches. In the phonemic fluency task, the right cerebellar lesion (RC) group produced significantly fewer words compared to the left cerebellar lesion (LC) group and healthy controls, particularly over the first 15 seconds of the task with no increase in errors and significantly fewer switches over the entire task. In the semantic fluency task there was only a modest decrease in total words in the RC group compared to controls. RC lesions impair fluency with many of the same performance characteristics as left prefrontal lesions. This supports the hypotheses of a prefrontal-lateral cerebellar system for modulation of attention/executive or strategy demanding tasks.

White matter and neurocognitive changes in adults with chronic traumatic brain injury.

Diffusion tensor imaging was used to investigate white matter (WM) integrity in adults with traumatic brain injury (TBI) and healthy adults as controls. Adults with TBI had sustained severe vehicular injuries on the average of 7 years earlier. A multivariate analysis of covariance with verbal IQ as the covariate revealed that adults with TBI had lower fractional anisotropy and higher mean diffusivity than controls, specifically in the three regions of interest (ROIs), the centrum semiovale (CS), the superior frontal (SPF), and the inferior frontal (INF). Adults with TBI averaged in the normal range in motor speed and two of three executive functions and were below average in delayed verbal recall and inhibition, whereas controls were above average. Time since injury, but not age, was associated with WM changes in the SPF ROI, whereas age, but not time since injury, was associated with WM changes in the INF ROI, suggesting that the effects of WM on time since injury may interact with age. To understand the utility of WM changes in chronic recovery, larger sample sizes are needed to investigate associations between cognition and WM integrity of severely injured individuals who have substantial cognitive impairment compared to severely injured individuals with little cognitive impairment. (JINS, 2009, 15, 130-136.).

Late proton magnetic resonance spectroscopy following traumatic brain injury during early childhood: relationship with neurobehavioral outcomes.

We sought to extend previous research that demonstrates reduced neurometabolite concentrations during the chronic phase of pediatric traumatic brain injury (TBI) in children injured during early childhood. We hypothesized that young children with TBI in the chronic phase post-injury would have lower N-acetyl aspartate (NAA) metabolite concentrations in gray and white matter in comparison to controls. We also hypothesized that metabolite levels would be correlated with acute TBI severity and neurobehavioral skills. Ten children with a history of TBI between the ages of 3 and 6 years were compared to an age, gender, and race-matched group of 10 children with a history of an orthopedic injury (OI). Children completed neurobehavioral testing at 12 months post-injury. Proton magnetic resonance (MR) spectroscopy was completed at least 12 months post-injury when the children were 6-9 years old. Groups were compared on metabolite concentrations in the medial frontal gray matter and left frontal white matter. Metabolite levels were correlated with Glasgow Coma Scale (GCS) scores and neurobehavioral functioning. There was a trend for lower NAA concentrations in the medial frontal gray matter for the TBI group. Late NAA and Cr levels in the medial frontal gray matter and NAA levels in the left frontal white matter were strongly positively correlated with initial GCS score. Metabolite levels were correlated with some neurobehavioral measures differentially for children with TBI or OI. Some neurometabolite levels differed between the TBI and OI groups more than 1 year post-injury and were related to injury severity, as well as some neurobehavioral outcomes following TBI during early childhood.

Detrimental effects of aging on outcome from traumatic brain injury: a behavioral, magnetic resonance imaging, and histological study in mice.

Considerable evidence indicates that outcomes from traumatic brain injury (TBI) are worse in the elderly, but there has been little preclinical research to explore potential mechanisms. In this study, we examined the age-related effects on outcome in a mouse model of controlled cortical impact (CCI) injury. We compared the responses of adult (5-6 months old) and aged (21-24 months old) male mice following a moderate lateral CCI injury to the sensorimotor cortex. Sensorimotor function was evaluated with the rotarod, gridwalk and spontaneous forelimb behavioral tests. Acute edema was assessed from hyperintensity on T2-weighted magnetic resonance images. Blood-brain barrier opening was measured using anti-mouse immunoglobulin G (IgG) immunohistochemistry. Neurodegeneration was assessed by amino-cupric silver staining, and lesion cavity volumes were measured from histological images. Indicators of injury were generally worse in the aged than the adult mice. Acute edema, measured at 24 and 48 h post-injury, resolved more slowly in the aged mice (p < 0.01). Rotarod recovery (p < 0.05) and gridwalk deficits (p < 0.01) were significantly worse in aged mice. There was greater (p < 0.01 at 3 days) and more prolonged post-acute opening of the blood-brain barrier in the aged mice. Neurodegeneration was greater in the aged mice (p < 0.01 at 3 days). In contrast, lesion cavity volumes, measured at 3 days post-injury, were not different between injured groups. These results suggest that following moderate controlled cortical impact injury, the aged brain is more vulnerable than the adult brain to neurodegeneration, resulting in greater loss of function. Tissue loss at the impact site does not explain the increased functional deficits seen in the aged animals. Prolonged acute edema, increased opening of the blood-brain barrier and increased neurodegeneration found in the aged animals implicate secondary processes in age-related differences in outcome.

Perceptual expertise effects are not all or none: spatially limited perceptual expertise for faces in a case of prosopagnosia.

We document a seemingly unique case of severe prosopagnosia, L. R., who suffered damage to his anterior and inferior right temporal lobe as a result of a motor vehicle accident. We systematically investigated each of three factors associated with expert face recognition: fine-level discrimination, holistic processing, and configural processing (Experiments 1-3). Surprisingly, L. R. shows preservation of all three of these processes; that is, his performance in these experiments is comparable to that of normal controls. However, L. R. is only able to apply these processes over a limited spatial extent to the fine-level detail within faces. Thus, when the location of a given change is unpredictable (Experiment 3), L. R. exhibits normal detection of features and spatial configurations only for the lower half of each face. Similarly, when required to divide his attention over multiple face features, L. R. is able to determine the identity of only a single feature (Experiment 4). We discuss these results in the context of forming a better understanding of prosopagnosia and the mechanisms used in face recognition and visual expertise. We conclude that these mechanisms are not "all-or-none," but rather can be impaired incrementally, such that they may remain functional over a restricted spatial area. This conclusion is consistent with previous research suggesting that perceptual expertise is acquired in a spatially incremental manner [Gauthier, I., & Tarr, M. J. Unraveling mechanisms for expert object recognition: Bridging brain activity and behavior. Journal of Experimental Psychology: Human Perception & Performance, 28, 431-446, 2002].

A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single-case experimental design.

Very few empirically validated interventions for improving metacognitive skills (i.e., self-awareness and self-regulation) and functional outcomes have been reported. This single-case experimental study presents JM, a 36-year-old man with a very severe traumatic brain injury (TBI) who demonstrated long-term awareness deficits. Treatment at four years post-injury involved a metacognitive contextual intervention based on a conceptualization of neuro-cognitive, psychological, and socio-environmental factors contributing to his awareness deficits. The 16-week intervention targeted error awareness and self-correction in two real life settings: (a) cooking at home; and (b) volunteer work. Outcome measures included behavioral observation of error behavior and standardized awareness measures. Relative to baseline performance in the cooking setting, JM demonstrated a 44% reduction in error frequency and increased self-correction. Although no spontaneous generalization was evident in the volunteer work setting, specific training in this environment led to a 39% decrease in errors. JM later gained paid employment and received brief metacognitive training in his work environment. JM's global self-knowledge of deficits assessed by self-report was unchanged after the program. Overall, the study provides preliminary support for a metacognitive contextual approach to improve error awareness and functional outcome in real life settings.

Trauma modulates amygdala and medial prefrontal responses to consciously attended fear.

Effective fear processing relies on the amygdala and medial prefrontal cortex (MPFC). Post-trauma reactions provide a compelling model for examining how the heightened experience of fear impacts these systems. Post-traumatic stress disorder (PTSD) has been associated with excessive amygdala and a lack of MPFC activity in response to nonconscious facial signals of fear, but responses to consciously processed facial fear stimuli have not been examined. We used functional MRI to elucidate the effect of trauma reactions on amygdala-MPFC function during an overt fear perception task. Subjects with PTSD (n = 13) and matched non-traumatized healthy subjects (n = 13) viewed 15 blocks of eight fearful face stimuli alternating pseudorandomly with 15 blocks of neutral faces (stimulus duration 500 ms; ISI 767 ms). We used random effects analyses in SPM2 to examine within- and between-group differences in the MPFC and amygdala search regions of interest. Time series data were used to examine amygdala-MPFC associations and changes across the first (Early) versus second (Late) phases of the experiment. Relative to non-traumatized subjects, PTSD subjects showed a marked bilateral reduction in MPFC activity (in particular, right anterior cingulate cortex, ACC), which showed a different Early-Late pattern to non-traumatized subjects and was more pronounced with greater trauma impact and symptomatology. PTSD subjects also showed a small but significant enhancement in left amygdala activity, most apparent during the Late phase, but reduction in Early right amygdala response. Over the time course, trauma was related to a distinct pattern of ACC and amygdala connections. The findings suggest that major life trauma may disrupt the normal pattern of medial prefrontal and amygdala regulation.

Susceptibility weighted imaging: neuropsychologic outcome and pediatric head injury.

Traumatic brain injury is among the most frequent pediatric neurologic disorders in the United States, affecting multiple aspects of neuropsychologic functioning. This study assessed the efficacy of susceptibility weighted imaging as a predictor of long-term neuropsychologic functioning after pediatric brain injury compared with magnetic resonance spectroscopic imaging. Susceptibility weighted imaging is a relatively new method that is considered superior to traditional magnetic resonance imaging sequences for detecting hemorrhagic diffuse axonal injury. In this study, imaging and spectroscopy were acquired 6 +/- 4 days after injury. Measures of neuropsychologic functioning were administered to 18 children and adolescents 1-4 years post injury. Negative correlations between lesion number and volume with neuropsychologic functioning were demonstrated. Lesion volume explained over 32% of the variance in cognitive performance, explaining at least an additional 20% beyond injury severity and age at injury alone and 19% beyond magnetic resonance spectroscopic metabolite variables. Exploratory analyses resulted in notable trends, with lesions in deeper brain regions more strongly associated with poorer neuropsychologic performance. Improved detection of the extent of diffuse axonal injury following a brain injury will allow for a better understanding of its association with long-term outcome, which in turn can improve prognostic efficacy for effective treatment planning.

Subcortical white matter metabolic changes remote from focal hemorrhagic lesions suggest diffuse injury after human traumatic brain injury.

OBJECTIVE: We used positron emission tomographic studies to prospectively examine the relationship between glucose and oxidative metabolism in the subcortical white matter (WM) acutely after traumatic brain injury (TBI). The objective was to determine the nature, extent, and degree of metabolic abnormalities in subcortical brain regions remote from hemorrhagic lesions. METHODS: Sixteen normal volunteers and 10 TBI patients (Glasgow Coma Scale score, 4-10; age, 17-64 yr; 6 with focal and 4 with diffuse injury) were studied. Each subject underwent dynamic positron emission tomographic studies using [(15)O]CO, (15)O(2), [(15)O]H(2)O, and fluorodeoxyglucose plus a magnetic resonance imaging scan acutely after TBI. Parametric images of the metabolic rate of oxygen and metabolic rate of glucose were generated, and a molar oxygen-to-glucose utilization ratio was calculated. Data from gray matter and WM remote from hemorrhagic lesions, plus whole brain, were analyzed. RESULTS: There was a significant reduction in the subcortical WM oxygen-to-glucose utilization ratio after TBI compared with normal values (3.99 +/- 0.77 versus 5.37 +/- 1.00; P < 0.01), whereas the mean cortical gray matter and whole-brain values remained unchanged. WM metabolic changes, which were diffuse throughout the hemispheres, were characterized by a reduction in the metabolic rate of oxygen without a concomitant drop in the metabolic rate of glucose. CONCLUSION: The extent and degree of subcortical WM metabolic abnormalities after moderate and severe TBI suggest that diffuse WM injury is a general phenomenon after such injuries. This pervasive finding may indicate that the concept of focal traumatic injury, although valid from a computed tomographic imaging standpoint, may be misleading when considering metabolic derangements associated with TBI.

The power of the human heart: a story of trauma and recovery and its implications for rehabilitation and healing.

Ms Trisha Meili revealed her identity as the Central Park Jogger in a presentation at Spaulding Rehabilitation Hospital in Boston in May 2003. Her co-presenter was Dr Jon Kabat-Zinn, whose teachings on mindfulness and meditation had been important in Ms Meili's rehabilitation process. This transcript of that conversation describes the various phases she underwent in her recovery, and documents the role of her self-discovered practice of mindfulness in restoring her emotional and physical functioning. Dr Kabat-Zinn reflects on the deeper meaning of the term "rehabilitation," and demonstrates its natural connections to the practice of meditation. A final question and answer section with audience members (clinicians, brain injury survivors and their families) documents the role of emotional support and inspiration in recovery from devastating injury.

[Neglect dyslexia owing to traumatic fronto-temporal right hemisphere bleeding]. / Neglektdyslexie nach traumatischer frontotemporaler Blutung rechts.

Apart from unilateral disturbance of the egocentric reference system, as it is traditionally known of neglect, there are also cases with unilateral disturbances of a stimulus-centered or object-centered reference system. In these cases the spatial position of the object, from the observer's perspective, plays only a limited role in the explanation of the problems with object perception. We describe a patient who, following head-brain trauma and a fronto-temporal bleeding, showed, beside traditional neglect, also a stimulus-centered left-sided disorder in word and object perception. Our investigations showed that this disorder (a) is independent of the position of the object in the environmental space, (b) comprises words and objects, and (c) is especially sensitive for changes in the first letters of a word. Conclusively, it yields from this case that at least three different reference systems of object representation should be distinguished in neglect, which can be disturbed independently from each other and may negatively influence the behavioral potential of the patients.