Utility of post-traumatic amnesia in predicting 1-year productivity following traumatic brain injury: comparison of the Russell and Mississippi PTA classification intervals.

BACKGROUND: Duration of post-traumatic amnesia (PTA) correlates with global outcomes and functional disability. Russell proposed the use of PTA duration intervals as an index for classification of traumatic brain injury (TBI) severity. Alternative duration-based schemata have been recently proposed as better predictors of outcome to the commonly cited Russell intervals. OBJECTIVE: Validate a TBI severity classification model (Mississippi intervals) of PTA duration anchored to late productivity outcome, and compare sensitivity against the Russell intervals. METHODS: Prospective observational data on TBI Model System participants (n=3846) with known or imputed PTA duration during acute hospitalisation. Productivity status at 1-year postinjury was used to compare predicted outcomes using the Mississippi and Russell classification intervals. Logistic regression model-generated curves were used to compare the performance of the classification intervals by assessing the area under the curve (AUC); the highest AUC represented the best-performing model. RESULTS: All severity variables evaluated were individually associated with return to productivity at 1 year (RTP1). Age was significantly associated with RTP1; however, younger patients had a different association than older patients. After adjustment for individually significant variables, the odds of RTP1 decrease by 14% with every additional week of PTA duration (95% CI 12% to 17%; p<0.0001). The AUC for the Russell intervals was significantly smaller than the Mississippi intervals. CONCLUSIONS: PTA duration is an important predictor of late productivity outcome after TBI. The Mississippi PTA interval classification model is a valid predictor of productivity at 1 year postinjury and provides a more sensitive categorisation of PTA values than the Russell intervals.

Predictive ability of preinjury stressful life events and post-traumatic stress symptoms for outcomes following mild traumatic brain injury: analysis in a prospective emergency room sample.

BACKGROUND: A subset of persons with mild traumatic brain injury (mTBI) experience long-term difficulties. Preinjury stress has been hypothesised to play a role in long-term maintenance of symptoms. OBJECTIVE: To investigate the predictive ability of preinjury stressful life events and post-traumatic stress symptoms to health-related quality of life and emotional distress after mTBI. METHODS: Within 2 weeks of injury, 186 participants with mTBI who were admitted to an emergency centre completed an interview and questionnaires regarding preinjury functioning, including the Stressful Life Events Questionnaire and the Post-Traumatic Stress Disorder Checklist. Outcomes were assessed at 3 months after injury and included the depression and anxiety subscales of the Brief Symptom Inventory, and the physical and mental component scores of the 36-item Short-Form Health Survey (SF-36). The incidence and type of stressful life events were reported. Hierarchical regression analyses were used to determine the predictive utility of Stressful Life Events Questionnaire and Post-Traumatic Stress Disorder Checklist after controlling for age, injury severity (complicated versus uncomplicated mild) and preinjury depression. RESULTS: Several potentially life-altering stressful events were endorsed by at least 25% of participants as having been experienced prior to injury. The incidence of stressful life events was a significant predictor of all four outcome variables. History of post-traumatic stress symptoms was predictive of scores on the SF-36 mental health component. CONCLUSIONS: A history of stressful events may predispose persons with mTBI to have poor outcomes. History of stress should be assessed during the early stages after mTBI to help identify those who could benefit from therapies to assist with adjustment and maximise recovery.

A multicentre study on the clinical utility of post-traumatic amnesia duration in predicting global outcome after moderate-severe traumatic brain injury.

BACKGROUND: Past research shows that post-traumatic amnesia (PTA) duration is a particularly robust traumatic brain injury (TBI) outcome predictor, but low specificity limits its clinical utility. OBJECTIVES: The current study assessed the relationship between PTA duration and probability thresholds for Glasgow Outcome Scale (GOS) levels. METHODS: Data were prospectively collected in this multicentre observational study. The cohort was a consecutive sample of rehabilitation patients enrolled in the National Institute on Disability and Rehabilitation Research funded TBI Model Systems (n = 1332) that had documented finite PTA duration greater than 24 h, and 1-year and 2-year GOS. RESULTS: The cohort had proportionally more Good Recovery (44% vs 39%) and less Severe Disability (19% vs 23%) at year 2 than at year 1. Longer PTA resulted in an incremental decline in probability of Good Recovery and a corresponding increase in probability of Severe Disability. When PTA ended within 4 weeks, Severe Disability was unlikely (<15% chance) at year 1, and Good Recovery was the most likely GOS at year 2. When PTA lasted beyond 8 weeks, Good Recovery was highly unlikely (<10% chance) at year 1, and Severe Disability was equal to or more likely than Moderate Disability at year 2. CONCLUSIONS: Two PTA durations, 4 weeks and 8 weeks, emerged as particularly salient GOS probability thresholds that may aid prognostication after TBI.

Emergence from minimally conscious state: insights from evaluation of posttraumatic confusion.

BACKGROUND: Guidelines for defining the minimally conscious state (MCS) specify behaviors that characterize emergence, including "reliable and consistent" functional communication (accurate yes/no responding). Guidelines were developed by consensus because of lack of empirical data. OBJECTIVE: To evaluate the utility of the operational threshold for emergence from posttraumatic MCS, by determining yes/no accuracy to questions of varied difficulty, including simple orientation questions, using all items from the Yes/No Subscale of the Mississippi Aphasia Screening Test. METHOD: Prospective observational study of a cohort of responsive patients recovering from traumatic brain injury in an acute inpatient brain injury rehabilitation program. RESULTS: Of the 629 observations from 144 participants, name recognition was the easiest yes/no question, with nonconfused individuals responding with 100% accuracy, whereas only 75% to 78% of confused participants on initial evaluation answered this question correctly. Generalized Estimating Equations analysis revealed that confused participants were more likely to respond inaccurately to all yes/no questions. Nonconfused participants had a reduction in odds of inaccuracy ranging from 45.6% to 99.7% (p = 0.001 to 0.02) depending on the type of yes/no question. CONCLUSIONS: Accuracy for simple orientation yes/no questions remains challenging for responsive patients in early recovery from traumatic brain injury. Although name recognition questions are relatively easier than other types of yes/no questions, including situational orientation questions, confused patients still may answer these incorrectly. Results suggest the operational threshold for yes/no response accuracy as a diagnostic criterion for emergence from the minimally conscious state should be revisited, with particular consideration of the type of yes/no questions and the requisite accuracy threshold for responses.

Serial yes/no reliability after traumatic brain injury: implications regarding the operational criteria for emergence from the minimally conscious state.

BACKGROUND: Published guidelines for defining the "minimally conscious state" (MCS) included behaviours that characterise emergence, specifically "reliable and consistent" functional interactive communication (accurate yes/no responding) and functional use of objects. Guidelines were developed by consensus because of the lack of empirical data to guide definitions. Criticism emerged that individuals with severely impaired cognition would have difficulty achieving the requisite threshold of accuracy and consistency proposed to demonstrate emergence from MCS. OBJECTIVE: To determine the utility of the operational threshold for emergence from post-traumatic MCS, by evaluating a measure of yes/no accuracy (Cognitive Test for Delirium, auditory processing subtest (CTD-AP).) METHODS: Prospective, consecutive cohort of responsive patients recovering from traumatic brain injury (TBI), including a subset meeting criteria for MCS at neurorehabilitation admission who improved and were able to undergo the study protocol. Participants were evaluated at least weekly, and given the CTD-AP to assess yes/no responding. RESULTS: Of the 1434 observations from 336 participants, 767 observations yielded inaccurate yes/no responses. 75 participants (22%) never attained consistently accurate yes/no responses at any time during their hospitalisation. Generalised estimating equations analysis revealed that confused participants were more likely to respond inaccurately to yes/no questions. Further, the subset of individuals who were in MCS on rehabilitation admission and improved, were also more likely to respond inaccurately to yes/no questions. CONCLUSIONS: Consistent yes/no accuracy is uncommon among responsive patients in early recovery from TBI. These results suggest that the operational threshold for yes/no response accuracy as a diagnostic criterion for emergence from MCS should be revisited.

Comparison of indices of traumatic brain injury severity: Glasgow Coma Scale, length of coma and post-traumatic amnesia.

BACKGROUND: Classification of traumatic brain injury (TBI) severity guides management and contributes to determination of prognosis. Common indicators of TBI severity include Glasgow Coma Scale (GCS) scores, length of coma (LOC) and duration of post-traumatic amnesia (PTA). OBJECTIVE: To compare GCS, LOC and PTA by examining distributions and intercorrelations and develop multivariable linear regression models for estimating LOC and PTA duration. METHODS: Prospective study of 519 of 614 consecutive patients with TBI. Indices of TBI severity studied were GCS, LOC, PTA and PTA-LOC (the interval from return of command-following to return of orientation). Candidate predictor variables for estimation of LOC, PTA and PTA-LOC intervals were age, years of education, year of injury (before 1997 vs 1997 or later), GCS, LOC (for PTA and PTA-LOC), pupillary responsiveness, type of injury, CT pathology and intracranial operations. RESULTS: Although there was a severity/response relationship between GCS and LOC, PTA and PTA-LOC intervals, there was overlap in these intervals between GCS severity categories. Age, year of injury, GCS, pupillary responsiveness and CT pathology were predictive of LOC. Age, years of education, year of injury, GCS, LOC, pupillary responsiveness and intracranial operations were predictive of PTA duration. Age, years of education, year of injury, GCS, LOC and pupillary responsiveness were predictive of PTA-LOC. GCS and LOC effects were influenced by age. CONCLUSIONS: Predictors for estimating LOC, PTA and PTA-LOC intervals were determined and simple equations were developed. These equations will be helpful to clinicians, researchers and those counselling family members of patients with TBI.

Brief assessment of severe language impairments: initial validation of the Mississippi aphasia screening test.

PRIMARY OBJECTIVE: To validate the Mississippi Aphasia Screening Test (MAST) which includes nine sub-scales measuring expressive and receptive language abilities. RESEARCH DESIGN: Evaluation of inpatients admitted to neurology, neurosurgery or rehabilitation units at two local hospitals and who were within 60 days of onset of a unilateral ischemic or haemorrhagic stroke (left hemisphere (LH; n=38); right hemisphere (RH; n=20)). Additional participants were recruited from the community to comprise a non-patient control sample (NP; n=36). METHODS: Data collection included administration of the MAST and chart review. RESULTS: The LH group showed more impairment than the RH and NP groups on summary scores. The LH group performed worse than the NP group on all sub-scales. The object recognition and verbal fluency sub-scales did not discriminate the stroke groups. CONCLUSION: Analyses suggest good criterion validity for the MAST in differentiating communication impairments among clinical and control samples.

Deep vein thrombosis: prevalence and risk factors in rehabilitation admissions with brain injury.

OBJECTIVE: To determine the prevalence and risk factors of deep vein thrombosis (DVT) among neurorehabilitation admissions with acquired brain injury (BI). METHODS: In this prospective, sequential case series, 709 consecutive initial neurorehabilitation patients with BI < 120 days-including traumatic brain injury (TBI; n = 360), intracranial hemorrhage (ICH; n = 213), primary brain tumor (n = 66), and hypoxia/other BI (n = 70)--were screened for evidence of DVT with lower extremity venous duplex ultrasonography (VDU). The admission screening protocol combined VDU and a commercial d-dimer (Dimertest [DDLx]) latex agglutination assay. DVT was considered present based upon VDU results only. RESULTS: DVT prevalence was 11.1%, and was higher with brain tumor (21.2%) and ICH (16%) than with TBI (6.7%) (chi2 test; p = 0.001). DVT risk factors identified by multivariable logistic regression analysis in the overall sample included older age (p = 0.002), type of BI (p = 0.04), DDLx (p = 0.0001), and greater postinjury duration (p = 0.0001), with a trend observed regarding lower Functional Independence Measure (FIM) locomotion (FIM-Loco) subscale score (p = 0.07). However, risk factors also varied with type of BI. Among patients with TBI, only DDLx (p = 0.001) and greater postinjury duration (p = 0.001) were associated with DVT. CONCLUSIONS: Admission venous duplex ultrasonography revealed occult proximal lower extremity deep vein thrombosis in 11% of neurorehabilitation patients with acquired brain injury. Deep vein thrombosis risk is multifactorial in this heterogenous patient population, with relative factor risk influenced by type of acquired brain injury. Semiquantitative d-dimer latex agglutination assay correlated significantly with presence of deep vein thrombosis.

Long-term neuropsychological outcome after traumatic brain injury.

OBJECTIVE: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. DESIGN: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. SETTING: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. PARTICIPANTS: One hundred eighty-two persons with complicated mild to severe traumatic brain injury. PRIMARY OUTCOME MEASURES: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. RESULTS: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. CONCLUSIONS: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.

OBJECTIVE: To investigate maintenance of gains after discharge from a postacute rehabilitation program. DESIGN: Longitudinal cohort study, with inclusion based on availability of subjects at three time points. SETTING: Comprehensive postacute rehabilitation program in the Southern United States. PARTICIPANTS: Thirty-four persons with medically documented complicated mild to severe traumatic brain injury; primarily male Caucasians with some college. MAIN OUTCOME MEASURES: Disability Rating Scale and the Community Integration Questionnaire completed at admission, discharge, and two follow-up time points. RESULTS: Repeated measures analyses, using time from injury to discharge as a covariate, revealed significant improvements on all measures from admission to discharge, with no significant change from discharge to either of the follow-up periods. However, substantial changes were noted in individual cases. CONCLUSIONS: The results indicate that gains made by persons with traumatic brain injury during postacute rehabilitation are generally maintained at long-term follow-up, but changes occur in individual cases. Long-term services may help prevent decline in individual cases.

Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury.

OBJECTIVE: To evaluate whether early neuropsychologic testing is useful in predicting long-term productivity outcome after traumatic brain injury (TBI). DESIGN: Validation cohort prediction study. SETTING: Four inpatient brain injury rehabilitation programs participating in the Traumatic Brain Injury Model Systems project. PARTICIPANTS: A total of 293 adults with nonpenetrating TBI. MAIN OUTCOME MEASURES: Fifteen neuropsychologic tests were administered to patients who emerged from posttraumatic amnesia before rehabilitation discharge. Test scores were classified in the normal range or impaired range, using objective criteria. Outcome was defined as productive if the patient was competitively employed or enrolled full time in regular education. RESULTS: Productivity at follow-up was predicted by completion of at least 1 neuropsychologic test before discharge, by an injury-test interval of less than 2 months, and by normal range scores on 10 of the 15 neuropsychologic tests. Normal range scores on these tests increased the probability of a productive outcome by 40% to 130%. CONCLUSIONS: Neuropsychologic testing can help predict long-term productivity even when performed before discharge from inpatient rehabilitation and at variable injury-test intervals. Early testing should be interpreted in relation to injury-test interval. Because tests of multiple neuropsychologic domains predicted outcome, comprehensive evaluations might be more useful in predicting outcome.

Conceptual dilemmas in evaluating individuals with severely impaired consciousness.

States of severely impaired consciousness (SIC) are characterized by cognitive and motor limitations. This case report describes a 45-year-old female with impaired consciousness who began to 'walk'. She initially presented to the hospital unresponsive and was subsequently diagnosed with metabolic encephalopathy due to severe hypoglycaemia. Traditional indices of consciousness indicated a low level of responsiveness; however, during physical therapy, she displayed reciprocal walking movements when lifted to a standing position by two therapists. Despite her ability to walk increased distances during and after neurorehabilitation, she was unable to consistently demonstrate responses indicative of higher levels of consciousness. This case illustrates the challenge of rating patients with limited behavioural repertoire using established measures of impaired consciousness.

Prevalence, attitudes and knowledge of high school pupils towards drugs and other addictions: implications for school health education in Israel.

One hundred and fifteen high school pupils from Holon (a city in the center of Israel) participated in a study about the prevalence, knowledge and attitudes of these pupils towards drugs and other addictions (cigarettes and alcohol). Their mean age was 16.13 (+/-1.59) years; 43.9% were boys and 56.1% were girls. A total of 1.6% of the pupils regularly used illicit drugs, and an additional 11.3% were offered drugs. A total of 24% of the pupils smoked regularly (at least during the past year), and 42% consumed alcoholic beverages regularly. Their knowledge concerning illicit drugs was found to be inadequate; they correctly answered only 50% of the total study questions. A more liberal attitude towards illicit drugs was found with increasing age. Pupils who consumed illicit drugs received a higher scoring for their knowledge concerning the characteristics of various illicit drugs, as well as to having a more liberal attitude. The self image of the pupils who had experience with illicit drugs was lower (in two separate tests) in comparison to their peers. As a result of our study, our recommendation is to include the subject of illicit drugs, their dangers and prevention of their use in the official school curriculum from elementary school and during all subsequent school years.

Enhancing conversation skills in children with autism via video technology. Which is better, "self" or "other" as a model?

The present study was designed to compare the efficacy of "self" versus "other" video-modeling interventions. Five children with autism ranging in age from 4 to 11 were taught to answer a series of conversation questions in both self and other video-modeled conditions. Results were evaluated using a combination of a multiple baseline and alternating treatments design. Three out of the five participants performed at levels of 100% accuracy at posttreatment. Results indicated no overall difference in rate of task acquisition between the two conditions, implying that children who were successful at learning from video in general, learned equally as well via both treatment approaches. Anecdotal evidence suggested that participants who were successful with video treatment had higher visual learning skills than children who were unsuccessful with this approach. Results are discussed in terms of a visual learning model for children with autism.

Cancer Patients and their Spouses: Gender and its Effect on Psychological and Social Adjustment.

The aim of this research was to examine the effects of gender on the social adjustment and psychological distress experienced by cancer patients and their spouses. A total of 87 patients and spouses participated in the study, with the patients undergoing active medical treatment (chemotherapy, radiation or both) and three months post-diagnosis. Three questionnaires were used to collect data: a personal information one; the Brief Symptom Inventory (BSI), in which stress was examined; and the PAIS-SR, in which psychosocial adjustment to physical illness was examined. Both cancer patients and their spouses reported the same level of psychological distress and difficulties in social adjustment in most areas studied. Patients reported more difficulties in relationships with extended family and in sexual relations than their spouses did. In the area of social environment, spouses reported higher levels of difficulties than patients. Both men and women reported difficulties with social adjustment in most areas studied. Women reported more difficulties with social environment. As for psychological stress, generally men as patients and as spouses reported higher levels of anxiety. As patients, men reported higher levels of paranoia.

A review of outcome after moderate and severe closed head injury with an introduction to life care planning.

Forensic consultation regarding moderate and severe closed head injury (CHI) generally focuses on determination of severity of residual deficits and the implications of these deficits for future health care needs, personal independence, and employment. This information can be used to develop a life care plan that describes the patient's needs for continued medical care, rehabilitation, and daily assistance or supervision and estimates the long-term costs for these services. This article provides brief reviews of CHI classification, epidemiology, residual deficits, expected outcomes, and factors predictive of outcome. An introduction to the process of developing a life care plan is presented.

Wechsler Adult Intelligence Scale-Revised Block Design broken configuration errors in nonpenetrating traumatic brain injury.

Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.

Contribution of functional ratings to prediction of longterm employment outcome after traumatic brain injury.

The present study investigated the contribution of functional ratings to prediction of employment outcome after traumatic brain injury (TBI). Previous studies have suggested that functional ratings obtained at a significant time post-injury can supplement neurologic, pre-injury, neuropsychologic, and other post-injury variables in predicting long-term employment outcome. Functional ratings studied were patients' needs for physical, cognitive, and behavioural supervision. This investigation also addressed the issue of predicting long-term outcome for the select group of TBI patients who receive post-acute brain injury rehabilitation. Subjects were 76 patients with TBI. The mean age (25th, 50th, and 75th percentiles) was 32 (22, 28, 39) years and mean premorbid education level was 13 (12, 12, 14) years. Predictors studied were severity of injury, premorbid education level, pre-injury substance use, and needs for physical, cognitive and behavioural supervision at discharge from post-acute rehabilitation. Supervision needs ratings were obtained an average of 9.6 (4.2, 5.9, 11.2) months post-injury. Productivity status was assessed an average of 22.5 (12.6, 20.7, 30.5) months post-injury and 12.9 (4.9, 12.4, 16.6) months post-discharge from treatment. Spearman correlation coefficients revealed that premorbid educational level, pre-injury substance use, and needs for physical and behavioural supervision were related to long-term functional outcome (p < 0.05). However, multiple logistic regression analysis revealed that only level of pre-injury substance use was predictive of long-term productivity outcome once adjusted for the effects of the other predictors. Patients with no history of pre-injury substance use were more than eight times as likely to be employed at follow-up as those with a history of pre-injury substance abuse (p < 0.01).

Impaired awareness and employment outcome after traumatic brain injury.

Inaccurate self-awareness is a common finding after traumatic brain injury. Such impaired awareness has been hypothesized to limit patients' eventual functional outcomes by decreasing motivation for treatment and resulting in selection of inappropriate long-term goals. Previous investigations of the association between impaired awareness and employment outcome have produced inconsistent results. The present article reviews these studies and presents the results of our new investigation of this issue. In addition, we studied the comparability of two methods of measuring impaired awareness. Results provided strong support for a positive relationship between accurate self-awareness and favorable employment outcome at follow-up.