Patterns and predictors of follow-up in patients with mild traumatic brain injury.

BACKGROUND: This study was undertaken to identify factors that influence follow-up for patients with mild traumatic brain injury (MTBI). METHODS: One hundred and ninety-nine consecutive inpatients diagnosed with MTBI at a Trauma Centre (or TC) were monitored for establishment of care with a brain injury specialist after discharge. Bivariate statistics were calculated to determine subject characteristics impacting the decision to pursue TBI-related specialty care. RESULTS: One hundred and nineteen patients (59.8%) followed up with the TC for routine post-injury care. Patients who followed up were older (age >40: OR = 2.48, p = 0.01, 95% CI = 1.03-8.96) and had longer hospital lengths of stay (LOS > 3 days: OR = 2.99, p < 0.001, 95% CI = 1.33-7.67). Upon follow-up, providers identified 20 patients (16.8%) with persistent neurologic symptoms, seven (3.5%) of whom saw a brain injury specialist. Lack of insurance significantly decreased the likelihood of follow-up with the TC and/or establishment of care with a TBI specialist. (OR = 0.76, p = 0.01, 95% CI = 0.62-0.95). CONCLUSIONS: Being insured was strongly predictive for follow-up at the TC and for establishing with a brain injury specialist post-MTBI. The TC post-injury visit identified MTBI patients with persistent symptoms, suggesting post-acute TC follow-up is an important venue for MTBI sequelae screening and referral.

The Rehabilitation Institute of Chicago Military Traumatic Brain Injury Screening Instrument: determination of sensitivity, specificity, and predictive value.

BACKGROUND: Traumatic brain injury (TBI) is referred to as the signature injury of the wars in Iraq and Afghanistan. Given the prevalence of TBI in military personnel, there is a need for validated instruments tailored to accurately screen for TBI in this population. METHODS: Three hundred service members or veterans underwent a novel screen and a comprehensive diagnostic assessment to identify the occurrence of TBI and/or the presence of posttraumatic stress disorder. Negative predictive value, positive predictive value, sensitivity, and specificity were calculated. RESULTS: This screening tool for TBI yielded sensitivity of 96%, specificity of 64%, negative predictive value of 95%, and positive predictive value of 69%. CONCLUSION: The Rehabilitation Institute of Chicago Military Traumatic Brain Injury Screening Instrument has a high negative predictive value and high sensitivity for TBI. This tool identifies individuals likely to have sustained a TBI. Moreover, it detects those who are likely not to have sustained such an injury and can be reassured in this regard. Because such distinction can be made with a high degree of accuracy in rapid and cost-effective fashion, it represents an important contribution to the armamentarium of TBI screening tools.

A "virtually minimal" visuo-haptic training of attention in severe traumatic brain injury.

BACKGROUND: Although common during the early stages of recovery from severe traumatic brain injury (TBI), attention deficits have been scarcely investigated. Encouraging evidence suggests beneficial effects of attention training in more chronic and higher functioning patients. Interactive technology may provide new opportunities for rehabilitation in inpatients who are earlier in their recovery. METHODS: We designed a "virtually minimal" approach using robot-rendered haptics in a virtual environment to train severely injured inpatients in the early stages of recovery to sustain attention to a visuo-motor task. 21 inpatients with severe TBI completed repetitive reaching toward targets that were both seen and felt. Patients were tested over two consecutive days, experiencing 3 conditions (no haptic feedback, a break-through force, and haptic nudge) in 12 successive, 4-minute blocks. RESULTS: The interactive visuo-haptic environments were well-tolerated and engaging. Patients typically remained attentive to the task. However, patients exhibited attention loss both before (prolonged initiation) and during (pauses during motion) a movement. Compared to no haptic feedback, patients benefited from haptic nudge cues but not break-through forces. As training progressed, patients increased the number of targets acquired and spontaneously improved from one day to the next. CONCLUSIONS: Interactive visuo-haptic environments could be beneficial for attention training for severe TBI patients in the early stages of recovery and warrants further and more prolonged clinical testing.

Postconcussive complaints, cognition, symptom attribution and effort among veterans.

The etiology of postconcussive symptoms is not clearly understood. Development of etiological models of those symptoms will be helpful for accurate diagnosis and for planning effective treatment. Such a model should characterize the role of subject characteristics (education, premorbid intelligence), social psychological factors and symptom validity. Toward that end, the present study examined the association of postconcussive complaints and cognitive performance with symptom attribution and level of effort on testing. In a sample of 155 veterans, attribution to concussion was associated with endorsement of more severe postconcussive complaints, after controlling for the effects of other factors such as subject characteristics. Similarly, effort was associated with cognitive performance after controlling for the effects of these other factors. The present findings are consistent with previous reports that illness perception and effort on testing are associated with postconcussive complaints. This supports previous recommendations to routinely educate all concussion patients immediately after injury to reduce distorted perceptions and related persistent complaints. Finally, these findings highlight a need for routine assessment of patients' perception of their injury to identify cases that may require psychotherapy to address any misattributions that develop.

Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention study.

OBJECTIVES: : To assess the efficacy of acupuncture in treating insomnia in traumatic brain injury (TBI) survivors as compared to medication, to determine whether acupuncture has fewer cognitive and affective adverse effects than does medication. PARTICIPANTS: : Twenty-four adult TBI survivors, randomized to acupuncture or control arms. SETTING: : Outpatient rehabilitation clinic. MEASURES: : Insomnia Severity Index (degree of insomnia); actigraphy (sleep time); Hamilton Depression Rating Scale (depression); Repeatable Battery for the Assessment of Neuropsychological Status and Paced Auditory Serial Addition Test (cognitive function) administered at baseline and postintervention. RESULTS: : Sleep time did not differ between the treatment and control groups after intervention, whereas cognition improved in the former but not the latter. CONCLUSION: : Acupuncture has a beneficial effect on perception of sleep or sleep quality and on cognition in our small sample of patients with TBI. Further studies of this treatment modality are warranted to validate these findings and to explore factors that contribute to treatment efficacy.

Tolerance of a virtual reality intervention for attention remediation in persons with severe TBI.

OBJECTIVE: To evaluate the feasibility of applying virtual reality and robotics technology to improve attention in patients with severe traumatic brain injury (TBI) in the early stages of recovery. METHODS: A sample of TBI patients (n=18, aged 19-73) who were receiving acute inpatient rehabilitation completed three-dimensional cancellation exercises over two consecutive days in an interactive virtual environment that minimized distractions and that integrated both visual and haptic (tactile) stimuli. Observations of behaviour during the intervention and of the instructions needed to encourage compliance were recorded. Performance data were compiled to assess improvement across three different treatment conditions. OUTCOMES: Fifteen of the 18 patients demonstrated tolerance of the virtual environment by completing the entire treatment protocol. Within-subjects comparisons of target acquisition time during treatment showed that a treatment condition that included haptic cues produced improved performance compared to a condition in which such cues were not provided. Separating out participants who were in post-traumatic amnesia showed that this group also demonstrated improvement in performance across trials despite their memory impairment. CONCLUSIONS: It is proposed that attention exercises using virtual environments are well-tolerated and engaging and that they could be beneficial for inpatients with severe TBI.

Actigraphy for assessment of sleep in traumatic brain injury: case series, review of the literature and proposed criteria for use.

PRIMARY OBJECTIVE: To demonstrate that actigraphy is an appropriate means of measuring sleep in patients with TBI and to define parameters for its use in this population. RESEARCH DESIGN: Case series and review of the literature. METHODS AND PROCEDURES: Subjects participating in one of two externally funded studies addressing the role of acupuncture in treating insomnia in TBI underwent actigraphy for the purpose of quantifying sleep time. Cases selected for presentation illustrate challenges in use of this modality in this population. MAIN OUTCOMES AND RESULTS: Caution should be exercised in interpreting actigraphy data in patients with TBI and (1) motor impairment or (2) cognitive and behavioural impairments which include agitation and impulsivity. CONCLUSIONS: Guidelines for use of actigraphy in patients with TBI are proposed: (1) Patients should be at Rancho Los Amigos cognitive level of III or above; (2) Patients with paresis, significant spasticity or contractures of one or more limbs should have the device placed on the least affected limb; and (3) For patients with tetraparesis, the device may not be an appropriate instrument for measurement of sleep; if it is to be used, consideration should be given to placing it on the head, rather than limbs or torso.

The effect of sleep medications on cognitive recovery from traumatic brain injury.

OBJECTIVE: To summarize the literature on the available pharmacotherapy for insomnia and the adverse cognitive effects of those options in persons with traumatic brain injury (TBI). DESIGN: Ovid/MEDLINE databases were searched by using the following key words: "brain injury," "sleep initiation and maintenance disorders," "hypnotics and sedatives," "benzodiazepines," "trazodone," and "neuronal plasticity." RESULTS: The reviewed literature consistently reported that benzodiazepines and atypical gamma-aminobutyric acid (GABA) agonists result in cognitive impairment when plasma levels are at their peak. Evidence of residual effects on cognition was reported for benzodiazepines but was seen less often in atypical GABA agonists. However, evidence has also been presented that GABA agonists have adverse effects on neuroplasticity, raising concerns about their use in patients recovering from TBI. CONCLUSIONS: Use of benzodiazepines in TBI has been discouraged and some authors also advocate caution in prescribing atypical GABA agonists. Alternate treatments including trazodone and a newer class of agents, melatonin agonists, are highlighted, along with the limited data available addressing the use of these medications in TBI. Finally, suggestions are offered for further research, especially on topic related to neural plasticity and functional recovery.