Self and parent ratings of executive functioning after adolescent traumatic brain injury.

OBJECTIVE: To examine the level of agreement between adolescents with traumatic brain injury (TBI) and their parents in standardized ratings of executive functioning, and to determine correlates of discrepancies between those ratings. PARTICIPANTS: Ninety-eight 11- to 16-year-old adolescents with TBI and their parents, and 97 neuropsychologically healthy controls. METHOD: Five-year consecutive series of rehabilitation referrals for TBI. MEASURES: Behavior Rating Inventory of Executive Function-Self Report (BRIEF-SR) and Behavior Rating Inventory of Executive Function (BRIEF) parent report versions. RESULTS: Self and parent ratings were moderately positively correlated in both the TBI group and the control group, but parents generally identified more executive dysfunction than did the adolescents. Parent-adolescent discrepancies were statistically significantly greater in the TBI group than in the control group on the Metacognitive index but not the Behavioral Regulation index. The degree of the former discrepancy was predicted by duration of coma in the TBI group. CONCLUSIONS: Adolescents with more severe TBI may underestimate their own degree of executive dysfunction in daily life, particularly aspects of metacognitive abilities, possibly, in part, because of an organic-based lack of deficit awareness.

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DESIGN: Case-control, retrospective. PARTICIPANTS: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. RESULTS: Aspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). CONCLUSION: The majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial.

OBJECTIVE: To determine whether passive leg movement during tilt table mobilization reduces the incidence of orthostatic dysfunction in mobilization of patients being comatose or semi-comatose early after brain injury. DESIGN: Randomized crossover pilot trial using sequential testing. SETTING: Neurorehabilitation hospital. SUBJECTS: Nine patients still unconscious within the first three months of brain injury (5 men, 4 women; age 51 +/- 20 years). INTERVENTION: Patients were subjected once to a conventional tilt table and once to a tilt table with an integrated stepping device. MAIN OUTCOME MEASURE: The number of syncopes/presyncopes (orthostatic hypotension, tachypnoea, increased sweating) during interventions. RESULTS: One patient had presyncopes on both devices, six patients had presyncopes on the conventional tilt table but not on the tilt table with integrated stepping, and two patients did not exhibit presyncopal symptoms on either device. There were significantly more incidents on the tilt table without than on the one with an integrated stepping device (P < 0.05) at tilts of 50 or 70 degrees respectively. CONCLUSION: Patients tolerate greater degrees of head-up tilt better with simultaneous leg movement.

Establishing a prognosis for functional outcome during coma recovery.

PRIMARY OBJECTIVE: One of the most challenging tasks for clinicians caring for survivors of severe brain injury (BI) is establishing a prognosis, for long-term functional outcome, while the patient is unconscious. The objective of this article is to report findings regarding the prediction of functional outcomes 1-year after severe BI using data available when the patient is unconscious. RESEARCH DESIGN: Longitudinal prognostication study. METHODS AND PROCEDURES: Persons unconscious after severe BI who present to inpatient (IP) rehabilitation hospitals in the Midwestern US are enrolled in an ongoing study. Each subject is followed for 1-year and the final outcome interview includes approximately 70 questions; 32 of these questions are from the Craig Handicap Assessment and Reporting Technique (CHART). A sample of 63 persons was abstracted from the study database to examine the predictability of 42 independent variables and 16 dichotomous outcomes. MAIN OUTCOMES AND RESULTS: Twelve of the 16 dichotomous outcomes were found to be significantly predictable (p < 0.05). These involve activity, participation, environment and quality of life outcomes. Ten predictors were found to be significant (p < 0.05): aetiology (Closed Head Injury vs. Other BI), presence of urinary tract infection (UTI), seizure, hypertension during IP rehabilitation, veteran benefit eligibility, health insurance, marital status at injury, whether or not recovery of consciousness occurred within 1 year, the number of days between injury and admission to acute rehabilitation and the average length of IP rehabilitation stay. Eight of the 10 variables are available early after injury or when the patient is unconscious.

[The pharmacological treatment of abulic posttraumatic state in children-preliminary report]. / Leczenie farmakologiczne pourazowego stanu abulicznego u dzieci--doniesienie wstepne.

UNLABELLED: The aim of the study was the evaluation of clinical condition of the children treated by Gliatilin and Dexamin for posttraumatic abulic state. MATERIAL AND METHOD: The study included 12 children (8 boys, 4 girls) at the age range between 7-16 years (mean age 7.8 years). The evaluation of clinical condition was performed on admission to the Department, and then at 3rd, 6th and 12th month after head injury. The authors analyzed the kind of injury (posttraumatic changes in neuroimaging) and evolution of patients' clinical condition in the follow-up. RESULTS: The most commonly observed reasons of trauma were motor vehicle accidents. The kind of pathology found on the base of neuroimaging did not affect the results of treatment. The patients were treated by Gliatilin, Dexamin or both. In spite of this treatment all children were rehabilitated and their hearing, sight and speech organ were stimulated. Six months after injury only one patient still presented abulic state and six of our patients were in good general condition. None of our patients revealed abulic state after 12 months of head trauma. In two children the Dexamin treatment was given up for seizures. We did not observe any side effects of Gliatilin. CONCLUSIONS: The kind of trauma and posttraumatic intracranial pathology do not determine the prognosis. The evaluation of treatment should be performed after 6-12 months. Gliatilin and Dexamin treatment improves the clinical state of patients with posttraumatic abulic state.

Persons with disorders of consciousness: are oral feedings safe/effective?

PRIMARY OBJECTIVE: Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. RESEARCH DESIGN: Descriptive, retrospective study. METHODS AND PROCEDURES: Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. MAIN OUTCOMES AND RESULTS: Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n=10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n=15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (chi2 = 0.260, p = 0.610). Average cost of care for group 1 = US$45 759 and group 2 = US$41 056 (p = 0.634). CONCLUSION: Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.

Early clinical predictive factors during coma recovery.

In severe brain injury patients few studies have examined the role of early clinical factors emerging before recovery of consciousness. Patients suffering from vegetative state and minimally conscious state in fact may need variable periods of time for recovery of the ability to follow commands. In a previous study we retrospectively examined a population of very severe traumatic brain injury patients with coma duration of at least 15 days (prolonged coma), and we found, as significant predictive factors for the final outcome, the time interval from brain injury to the recovery of the following clinical variables: optical fixation, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia during coma recovery were also favourable prognostic factors for the final outcome. In a further study, also as for the neuropsychological recovery, the clinical variable with the best significant predictive value was the interval from head trauma to the recovery of safe oral feeding. In the present study the presence of psychomotor agitation diagnosed by means of LCF (score 4 = confused-agitated) at the admission time in rehabilitation predicted a statistically significant better outcome at the discharge time in comparison with patients without agitation.

Predicting one year clinical outcome in traumatic brain injury (TBI) at the beginning of rehabilitation.

Predicting long-term clinical outcome for patients with traumatic brain injury (TBI) at the beginning of rehabilitation provides essential information for counseling of the family and priority-setting for the limited resources in intensive rehabilitation. The objective of this study is to work out the probability of the one-year outcome at the beginning of rehabilitation. Sixty-eight patients with moderate-to-severe TBI and known one-year outcome were employed for outcome prediction using the logistic regression model. A large number of prospectively collected data at admission (age, Glasgow Coma Scale [GCS] Score, papillary response), during intensive care unit (ICU) management (duration of coma, intracranial pressure [ICP] and its progress) and at the beginning of rehabilitation (baseline Functional Independence Measure [FIM], Neuro-behavioral Cognitive Status Examination [NCSE] and Functional Movement Assessment [FMA]) were available for preliminary screening by univariate analysis. Six prognostic factors (age, GCS, duration of coma, baseline FIM, NCSC and FMA) were utilized for the final logistic regression model. Age, GCS and baseline FIM at the beginning of rehabilitation have been found to be independent predictors for one-year outcome. The accuracy of prediction for a good Glasgow Outcome Score is 68% and an outcome for disability (either moderate or severe) is 83%. Validation of this model using a new set of data is required.

Understanding and managing coma stimulation: are we doing everything we can?

The incidence of people surviving with traumatic brain injury is rising at a remarkable pace. Unfortunately, patients also experience some form of coma and significant deficits (ie, cognitive, functional, etc). The focus is shifting from saving these patients to trying to figure out what else can be done for them? In the past, patients were medically maintained, stabilized, and then sent to rehabilitation centers for coma stimulation, in the hope of waking up their reticular activating system. Today, healthcare professionals are being encouraged to research and explore the possibility of implementing structured coma stimulation programs as early as 72 hours postinjury in the intensive care unit. Starting early is of paramount importance to a patient's survival, quality of life, and overall long-term prognosis. The goal of this article is to educate healthcare professionals (in the hospital setting) about managing and implementing structured sensory stimulation sessions.

A preliminary investigation of road traffic accident rate after severe brain injury.

PRIMARY OBJECTIVE: to investigate the road traffic accident rate in patients who have resumed driving after severe brain injury. RESEARCH DESIGN: a retrospective study conducted by means of telephone interviews. METHODS AND PROCEDURES: The caregivers of 90 patients suffering from severe brain injury were included. All of the patients had sustained severe brain injury and prolonged coma, i.e. lasting for at least 48 hours. The caregivers were interviewed by means of a Questionnaire that investigated several aspects of driving competence after coma and the incidence of road traffic accidents. MAIN OUTCOMES AND RESULTS: All patient outcomes were evaluated by means of the Glasgow Outcome Scale (GOS). The 90 caregivers reported that 29 patients (32%) had resumed driving and that 11 of the 29 (38%) were subsequently involved in road traffic accidents. During the total duration of our patient population risk exposure, we found 11 cases in our study group, against the 4.7 expected cases calculated in the normal population. The relative risk of road traffic accidents in severe brain injury patients versus uninjured individuals was 2.3. CONCLUSIONS: Our preliminary data show that a subject who has suffered from severe brain injury and coma lasting for at least 48 hours has a statistically significant higher risk of being involved in a road traffic accident.

Role of premorbid factors in predicting safe return to driving after severe TBI.

PRIMARY OBJECTIVE: The present study explored the possibility of predicting post-injury fitness to safe driving in patients with severe traumatic brain injury (TBI) (n = 66). METHODS AND PROCEDURE: Sixteen different measures, derived from four domains (demo/biographic, medico-functional, neuropsychological, and psychosocial) were used as predictor variables, whereas driving outcomes were assessed in terms of driving status (post-TBI drivers versus non-drivers) and driving safety (number of post-TBI car accidents and violations). MAIN OUTCOMES AND RESULTS: About 50% of the patients resumed driving after TBI. Compared to post-TBI non-drivers, post-injury drivers had shorter coma duration. With regard to driving safety, the final multiple regression model combined four predictors (years post-injury, accidents and violations before TBI, pre-TBI-risky-personality-index, and pre-TBI-risky-driving-style-index) and explained 72.5% of variance in the outcome measure. CONCLUSIONS: Since the best three predictors of post-injury driving safety addressed patients' premorbid factors, the results suggest that in order to evaluate the actual possibility of safe driving after TBI, it would be advisable to consider carefully patients' pre-TBI histories.

Rehabilitative management of patients with disorders of consciousness: grand rounds.

BACKGROUND: There are no standards of care to guide the selection of rehabilitation assessment and treatment procedures for patients with disorders of consciousness. Recently, consensus-based recommendations for management of patients in the vegetative and minimally conscious states have been developed and disseminated in neurology and neurorehabilitation. This is an important first step toward achieving evidence-based guidelines of care. OBJECTIVE: Using a "Grand Rounds" format, we illustrate the application of consensus-based diagnostic, prognostic, and treatment recommendations in a patient who sustained severe traumatic brain injury with prolonged alteration in consciousness. After discussing the salient features of the case, we summarize the basic tenets of clinical care for this population.

Terapia Ocupacional en el estado vegetativo y de mínima conciencia: estimulación sensorial / Occupational therapy in vegetative and minimally conscious states: sensory stimulation

El objetivo fundamental de este trabajo ha consistido en registrar los cambios en las respuestas de los pacientes con traumatismo craneoencefálico grave, tratados mediante estimulación sensorial, valorar la sensibilidad a los cambios de las diferentes escalas de valoración administradas (The Rancho Los Amigos Level of Cognitive Function --RLA--, Disability Rating Scale --DRS-- y Coma/Near Coma Scale -CNCS--) y observar si es posible establecer un valor pronóstico con dichas escalas. Se aplicó un diseño cuasi experimental con medidas pre y post en un solo grupo. Se incluyeron 13 casos. Se les administraron las escalas de valoración al inicio, durante (quincenalmente), y al final del período de recogida de datos (17 semanas). El tratamiento consistió en sesiones diarias (30 minutos) de estimulación sensorial llevadas a cabo por una terapeuta ocupacional. Resultados: Las tres escalas resultaron útiles en la valoración de este tipo de pacientes, siendo la CNCS la más sensible atendiendo al porcentaje de mejoría y proporcionando información sobre posible pronóstico a lo largo del estudio (AU)

Role of semantic control of action in the comprehensive rehabilitation of patients recovering from prolonged post-traumatic coma.

BACKGROUND: Apraxia, broadly understood as the acquired inability to perform learned, skilled movements not caused by paresis or incomprehension, occurs with greater frequency among patients recovering from prolonged post-traumatic coma than has previously been reported. The present article prevents an evaluation of the effectiveness of a rehabilitation program called Semantic Priming, aimed at rebuilding praxis in these patients. MATERIAL/METHODS: Out of a consecutive series of 51 patients with post-traumatic coma lasting longer than 4 weeks treated at the centers represented by the authors, 24 were found to have pathological scores on the Boston Test of Praxis. These patients were divided into two matched groups, of whom the experimental group received the Semantic Priming program (involving the systematic use of verbal cues to prime movement activation patterns), and the control group did not. Progress was measured by the Boston Test of Praxis and a test developed by the authors on the basis of Luria's procedure for testing praxis. RESULTS: After 5 weeks of therapy the patients in the experimental group showed significantly greater improvement in all measured parameters (p<0.001). CONCLUSIONS: Apraxia in the broader sense is a more common problem among post-coma patients than heretofore recognized, and causes concrete problems in rehabilitation and adjustment to daily living. Our program based on the use of semantic priming of activation proved to be highly successful in remediating apraxia in these patients.

Sensory stimulation for brain injured individuals in coma or vegetative state.

BACKGROUND: Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. OBJECTIVES: To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. SEARCH STRATEGY: We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. SELECTION CRITERIA: Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. DATA COLLECTION AND ANALYSIS: Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. MAIN RESULTS: Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. REVIEWER'S CONCLUSIONS: This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state.

Rehabilitation outcome in a patient awakened from prolonged coma.

BACKGROUND: This article describes the rehabilitation of a patient recovering from a prolonged coma (defined as lasting longer than 4 weeks). The case is noteworthy because it exemplifies the possibilities and difficulties entailed in treating these patients, who are often regarded as too severely impaired to justify intensive rehabilitation efforts. CASE REPORT: The patient is a 28-year old Polish male, unmarried, who suffered serious closed head injuries in an automobile accident in April of 1999. He was in a comatose state for more than two months, with a GCS score of 5. When admitted for rehabilitation he was bedridden, with global aphasia, agraphia, limb apraxia, and executive dysfunction. The rehabilitation program developed for him is described in detail. RESULTS: Over the course of rehabilitation, which began in December 1999 and continues to this writing, the patient has regained locomotion capabilities (though with impairments), and his speech has improved considerably. The apraxia has largely resolved, and he is able to write his name and copy words. He is now capable of performing many activities of daily living. CONCLUSIONS: A comprehensive program of rehabilitation characterized by a strategic, heuristic approach is capable of achieving a good outcome even in very difficult cases, such as prolonged coma.