Cognitive Behavioral Intervention Compared to Telephone Counseling Early after Mild Traumatic Brain Injury: A Randomized Trial.

Many patients do not return to work (RTW) after mild traumatic brain injury (mTBI) because of persistent complaints that are often resistant to therapy in the chronic phase. Recent studies suggest that psychological interventions should be implemented early post-injury to prevent patients from developing chronic complaints. This study is a randomized, controlled trial that examines the effectiveness of a newly developed cognitive behavioral therapy (CBT) intervention (CBTi) compared to telephonic counseling (TC) in at-risk mTBI patients (patients with high reports of early complaints). Patients underwent either five sessions of CBT treatment or five phone conversations starting 4-6 weeks post-trauma. The main outcome measure was RTW 6 and 12 months post-trauma. Secondary measures comprised functional outcome at 6 and 12 months, and depression, anxiety, and reported post-traumatic complaints at 3, 6, and 12 months post-injury. After excluding dropouts, CBTi consisted of 39 patients and TC of 45 patients. No significant differences were found with regard to RTW, with 65% of CBTi patients and 67% of TC patients reporting a RTW at previous level. However, TC patients reported fewer complaints at 3 (8 vs. 6; p = 0.010) and 12 months post-injury (9 vs. 5; p = 0.006), and more patients in the TC group showed a full recovery 12 months post-injury compared to the CBTi group (62% vs. 39%). The results of this study suggest that early follow-up of at-risk patients can have a positive influence on patients' well-being, and that a low-intensive, low-cost telephonic intervention might be more effective than a CBT intervention at improving outcome in at-risk patients.

Poor symptom and performance validity in regularly referred Hospital outpatients: Link with standard clinical measures, and role of incentives.

We investigated the frequency of symptom validity test (SVT) failure and its clinical correlates in a large, heterogeneous sample of hospital outpatients referred for psychological assessment for clinical purposes. We studied patients (N=469), who were regularly referred for assessment to the psychology departments of five hospitals. Background characteristics, including information about incentives, were obtained with a checklist completed by the clinician. As a measure of over-reporting, the Structured Inventory of Malingered Symptomatology (SIMS) was administered to all patients. The Amsterdam Short-Term Memory test (ASTM), a cognitive underperformance measure, was only administered to patients who were referred for a neuropsychological assessment. Symptom over-reporting occurred in a minority of patients, ranging from 12% to 19% in the main diagnostic patient groups. Patients with morbid obesity had a low rate of over-reporting (1%). The SIMS was positively associated with levels of self-reported psychological symptoms. Cognitive underperformance occurred in 29.3% of the neuropsychological assessments. The ASTM was negatively associated with memory test performance. We found no association between SVT failure and financial incentives. Our results support the recommendation to routinely evaluate symptom validity in clinical assessments of hospital patients. The dynamics behind invalid symptom reporting need to be further elucidated.

Speed of finger tapping as a predictor of functional outcome after unilateral stroke.

OBJECTIVES: To determine (1) if the speed of finger tapping of the hand ipsilateral to the lesion (ie, unaffected hand) remains stable during the first 6 months after stroke and (2) if the speed of finger tapping of the unaffected hand is related to functional outcome after neurorehabilitation, which is of relevance to clinical practice. DESIGN: Prospective cohort study with measurements at admission to inpatient rehabilitation (t0), 4 weeks after admission (t1), at discharge (t2), and 3 months after discharge (t3). SETTING: Neurorehabilitation unit of a Dutch rehabilitation center. PARTICIPANTS: Fifty-seven patients with a unilateral first-ever stroke and 42 spouses (controls) of stroke patients without history of neurologic disorders were administered the finger-tapping test to generate normative scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Finger-tapping speed of the ipsilateral hand from the Amsterdam Neuropsychological Test battery. The Barthel Index, Frenchay Activities Index (FAI), and Sickness Impact Profile-68 (SIP-68) were also used as outcome measures. RESULTS: The speed of finger tapping of the ipsilateral hand improved significantly from t0 (mean, 44.13) to t1 (mean, 47.30, P=.02) but consecutively remained stable until 3 months after discharge. Four weeks after admission, the speed of finger tapping was comparable to the scores of the controls. The speed of finger tapping at admission was significantly correlated with the Barthel Index score at discharge (r=.39) and the FAI score at discharge (r=.32) and follow-up (r=.37) but not with the SIP-68 score (r=.28). Regression analyses showed that the Barthel Index score at discharge could be predicted by the initial Barthel Index score and finger tapping at admission (R(2)=.49); the variance of FAI score at discharge and follow-up was largely explained by the initial Barthel Index score. CONCLUSIONS: The speed of finger tapping improved over the first 4 weeks postadmission until normative speeds were reached and remained stable during the next 4 months. The speed of finger tapping correlated with functional outcome but not with quality of life; it was a predictor of activity of daily living functioning, although not a strong one. These findings suggest that the speed of finger tapping of the ipsilateral hand is a useful measure of recovery, although other variables such as the initial level of independent functioning are of more importance.

Assessment of apraxia: inter-rater reliability of a new apraxia test, association between apraxia and other cognitive deficits and prevalence of apraxia in a rehabilitation setting.

OBJECTIVE: To investigate the inter-rater reliability of a new apraxia test. Furthermore to examine the association of apraxia with other neuropsychological impairments and the prevalence of apraxia in a rehabilitation setting on the basis of the new test. DESIGN: Cross-sectional cohort study, involving 100 patients with a first stroke admitted to a rehabilitation centre in the Netherlands. MEASURES: General patient characteristics and stroke-related aspects. Cognitive screening involving apraxia, visuospatial scanning, abstract thinking and reasoning, memory, attention, planning and aphasia. RESULTS: The indices for inter-rater agreement range from excellent to poor. Significant correlations are found between apraxia and visuospatial scanning, memory, attention, planning and aphasia. The patients with apraxia perform significantly worse than the patients without apraxia on memory, the time needed to complete the tests for scanning and attention, and aphasia. The prevalence of apraxia is 25.3% in the total group, 51.3% in the left hemisphere stroke patients and 6.0% in the right hemisphere stroke patients. Patients with and without apraxia do not differ significantly concerning age, gender and type of stroke. CONCLUSION: The apraxia test has been shown to be a reliable instrument. Apraxia is often associated with aphasia, memory problems and mental slowness. This study shows that on the basis of the apraxia test, the prevalence of apraxia among patients in the rehabilitation centre is high, especially among patients with left hemisphere lesions.