Showing papers in "Journal of Head Trauma Rehabilitation in 2006"
TL;DR: An overview of the epidemiology and impact of TBI is presented, which shows that the number of Americans living with TBI-related disability and their efforts to return to a full and productive life are increasing.
Abstract: Traumatic brain injury (TBI) is an important public health problem in the United States and worldwide. The estimated 5.3 million Americans living with TBI-related disability face numerous challenges in their efforts to return to a full and productive life. This article presents an overview of the epidemiology and impact of TBI. Language: en
3,554 citations
TL;DR: Families and communities need to be cognizant of the needs of returning veterans with TBI and posttraumatic stress disorder and lessons learned from the sports concussion and civilian mild TBI literature are useful.
Abstract: Traumatic brain injury (TBI) is an important source of morbidity in the Iraq and Afghanistan wars. Although penetrating brain injuries are more readily identified, closed brain injuries occur more commonly. Explosion or blast injury is the most common cause of war injuries. The contribution of the primary blast wave (primary blast injury) in brain injury is an area of active research. Lessons learned from the sports concussion and civilian mild TBI literature are useful. Individuals with TBI and posttraumatic stress disorder require treatment of both conditions. Families and communities need to be cognizant of the needs of these returning veterans. Language: en
832 citations
TL;DR: Findings were similar to those from previous years in which rates of TBI were highest for young children (aged 0–4) and men, and the leading causes were falls and motor vehicle traffic.
Abstract: Traumatic brain injury (TBI) is an important public health problem in the United States. In 2003, there were an estimated 1,565,000 TBIs in the United States: 1,224,000 emergency department visits, 290,000 hospitalizations, and 51,000 deaths. Findings were similar to those from previous years in which rates of TBI were highest for young children (aged 0-4) and men, and the leading causes of TBI were falls and motor vehicle traffic.
783 citations
TL;DR: Insomnia is a prevalent condition after TBI requiring more clinical and scientific attention as it may have important repercussions on rehabilitation.
Abstract: OBJECTIVES To document the frequency of insomnia (according to DSM-IV and ICSD criteria), to describe its sociodemographic and clinical characteristics, and to identify potential predictors of insomnia in persons with traumatic brain injury (TBI). PARTICIPANTS AND PROCEDURE: Four hundred fifty-two participants aged 16 years and older with minor to severe TBI answered a questionnaire pertaining to quality of sleep and fatigue. MAIN OUTCOME MEASURES Proportion of participants fulfilling criteria for insomnia symptoms or syndrome. Validated measures of insomnia severity, fatigue level, and psychologic distress. Results of a logistic regression analysis. RESULTS Overall, 50.2% of the sample reported insomnia symptoms and 29.4% fulfilled the diagnostic criteria for an insomnia syndrome. For the latter participants, insomnia was a severe and chronic condition remaining untreated in almost 60% of cases. Risk factors associated with insomnia were milder TBIs, and higher levels of fatigue, depression, and pain. CONCLUSION Insomnia is a prevalent condition after TBI requiring more clinical and scientific attention as it may have important repercussions on rehabilitation.
280 citations
TL;DR: The strong association between the style of coping used to manage stress and emotional adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles.
Abstract: OBJECTIVES To examine the association between coping style and emotional adjustment following traumatic brain injury. PARTICIPANTS Thirty three individuals who had sustained a traumatic brain injury (mean duration of posttraumatic amnesia = 32 days) between 1(1/2) months and almost 7 years previously. MEASURES Coping Scale for Adults, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, State-Trait Anger Expression Inventory, and the Sickness Impact Profile. RESULTS Approximately 50% of the sample reported clinically significant levels of anxiety and depression. Coping characterized by avoidance, worry, wishful thinking, self-blame, and using drugs and alcohol was associated with higher levels of anxiety, depression, and psychosocial dysfunction and lower levels of self-esteem. Coping characterized by actively working on the problem and using humor and enjoyable activities to manage stress was associated with higher self-esteem. Lower premorbid intelligence (measured via the National Adult Reading Test) and greater self-awareness (measured via the Self-Awareness of Deficits Interview) were associated with an increased rate of maladaptive coping. CONCLUSIONS The strong association between the style of coping used to manage stress and emotional adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles. It is also possible that improving emotional adjustment may increase adaptive coping. The development and evaluation of interventions aimed at facilitating adaptive coping and decreasing emotional distress represent important and potentially fruitful contributions to enhancing long-term outcome following brain injury.
250 citations
TL;DR: Aggression is a common, fluctuating, and long-term problem following TBI, and the underlying association between aggression and psychosocial variables lends support to the provision of ongoing outreach services and psychological and behavioral interventions.
Abstract: OBJECTIVE: To assess the prevalence and predictors of aggressive behavior among traumatic brain injury (TBI) survivors at 6, 24, and 60 months postdischarge. DESIGN: Mixed cross-sectional and longitudinal data from a 5-year follow-up study of discharged TBI patients analyzed retrospectively. SETTING: A specialized Brain Injury Rehabilitation Service of a tertiary referral hospital. PATIENTS: Two hundred twenty-eight (228) patients with moderate to severe TBI. MAIN OUTCOME MEASURES: The Overt Aggression Scale; injury-related variables (in particular, Glasgow Coma and Outcome scales and posttraumatic amnesia duration); and a battery of postdischarge questionnaires (Beck Depression Inventory, Trauma Complaints List, General Health Questionnaire, etc). RESULTS: At any given follow-up period, 25% of the participants were classified as aggressive. Aggression, where present, was consistently associated with depression, concurrent traumatic complaints, younger age at injury, and low satisfaction with life rather than with injury, demographic, or premorbid characteristics. Depression was the factor that was most significantly associated with aggressive behavior at all times postinjury, followed by a younger age at the time of injury. CONCLUSIONS: Aggression is a common, fluctuating, and long-term problem following TBI. The underlying association between aggression and psychosocial variables lends support to the provision of ongoing outreach services and psychological and behavioral interventions for all affected TBI survivors. Language: en
235 citations
TL;DR: Interventions that minimize challenging behavior and disability may make a significant difference to the level of community integration experienced by people with severe TBI.
Abstract: OBJECTIVE To assess and identify predictive factors of community integration of people 3 to 15 years after severe traumatic brain injury (TBI). PARTICIPANTS Forty participants with severe TBI (an average of 8.8 years postinjury). MAIN OUTCOME MEASURES The Community Integration Questionnaire, the Community Integration Measure, and the Sydney Psychosocial Reintegration Scale. Data related to factors that may predict community integration were also collected. RESULTS There was considerable variation in the level of community integration. Discriminant function analyses identified the following factors as predictive of the level of community integration: severity of injury, age at the time of injury, level of disability, and challenging behavior. CONCLUSION Interventions that minimize challenging behavior and disability may make a significant difference to the level of community integration experienced by people with severe TBI.
162 citations
TL;DR: FPS holds promise for reducing child behavior problems, the most common and persistent sequelae of TBI, and is assessed in a randomized clinical trial.
Abstract: OBJECTIVE: To describe a family-centered problem-solving intervention (FPS) for pediatric traumatic brain injury (TBI), and to assess the efficacy of the intervention in a randomized clinical trial. PARTICIPANTS: Families of 32 school-aged children with moderate to severe TBI randomly assigned to FPS or usual care (UC) group. MAIN OUTCOME MEASURES: Child Behavior Checklist, Brief Symptom Inventory, Conflict Behavior Questionnaire. INTERVENTION: Seven-session problem-solving/skill-building intervention delivered over a 6-month period for the participating families. RESULTS: Parents in the FPS group reported significantly greater improvements in their children in internalizing symptoms, anxiety/depression, and withdrawal than did parents in the UC comparison group. CONCLUSIONS: FPS holds promise for reducing child behavior problems, the most common and persistent sequelae of TBI.
126 citations
TL;DR: Long-term follow-up of individuals with TBI should increase vigilance for, and prevention of, diagnoses frequently causing death (circulatory disorders) and diagnoses with a high relative risk of causing death in this population (seizures, septicemia, respiratory and digestive conditions, and external causes of injury).
Abstract: OBJECTIVE: To investigate causes of death in individuals with traumatic brain injury (TBI). DESIGN: Retrospective cohort study. SETTING: Utilized data from the TBI Model Systems National Database, the Social Security Death Index, death certificates, and the US population age-race-gender-cause-specific mortality rates for 1994. PATIENTS: Two thousand one hundred forty individuals with TBI completing inpatient rehabilitation in 1 of 15 National Institute on Disability and Rehabilitation Research-funded TBI Model Systems of Care between 1988 and 2001, and surviving past 1 year postinjury. MAIN OUTCOME MEASURES: Primary cause of death based on the International Classification of Diseases--9th Revision--Clinical Modification-coded death certificates. RESULTS: Individuals with TBI were about 37 times more likely to die of seizures, 12 times more likely to die of septicemia, 4 times more likely to die of pneumonia, and about 3 times more likely to die of other respiratory conditions (excluding pneumonia), digestive conditions, and all external causes of injury/poisoning than were individuals in the general population of similar age, gender, and race. CONCLUSION: Long-term follow-up of individuals with TBI should increase vigilance for, and prevention of, diagnoses frequently causing death (circulatory disorders) and diagnoses with a high relative risk of causing death in this population (seizures, septicemia, respiratory and digestive conditions, and external causes of injury).
109 citations
TL;DR: The potential uses and current literature related to the use of serum biomarkers for outcome prediction after adult and pediatric TBI are reviewed, limitations of the literature, and future direction for this field are reviewed.
Abstract: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in adults and children. Predicting outcome after TBI is difficult, but it is important for acute management, counseling of family members, and provision of rehabilitation services. Serum biomarkers may be useful alone or in combination with clinical variables to predict outcome after TBI. This article reviews the potential uses of serum biomarkers for the clinician, current literature related to the use of serum biomarkers for outcome prediction after adult and pediatric TBI, limitations of the literature, and future direction for this field.
102 citations
TL;DR: Significant others have substantial influence on post-TBI driving outcome, and the importance of independent driving to community integration, as well as psychoeducation of survivors and their families are highlighted.
Abstract: OBJECTIVE: To examine the relations among driving status, perceptions of barriers to the resumption of driving, and community integration outcomes after traumatic brain injury (TBI). DESIGN: Correlational research using logistic and multiple regression analyses, analyses of variance, and covariance. PARTICIPANTS: Fifty-one survivors of TBI, 6 months to 10 years postinjury. MAIN OUTCOME MEASURES: Driving status postinjury, Community Integration Measure, and Craig Hospital Assessment and Reporting Technique. RESULTS: Perceptions of barriers to driving provided unique information in predicting subjective and objective indices of community integration, even after accounting for other potentially pertinent variables (eg, injury severity, social support, negative affectivity, and use of alternative transportation). Moreover, survivors who had not resumed driving showed poorer community integration than did those who had resumed driving. Social barriers such as directives against driving from significant others accounted for the most variance in survivor driving status. Decisions to cease driving were more common among those with no formal driving evaluation than among survivors who had been evaluated. CONCLUSIONS: Significant others have substantial influence on post-TBI driving outcome. The findings highlight the importance of independent driving to community integration, as well as psychoeducation of survivors and their families. Language: en
TL;DR: Patient characteristics, injury severity indicators, and cognitive functions were not associated with vocational status and to better understand post-MTBI vocational status, it is important to focus on subjective complaints that arise following the injury.
Abstract: OBJECTIVES: To explore the long-term relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status in persons with mild traumatic brain injury (MTBI), and to identify the symptoms that determine whether or not these individuals return to work DESIGN: Longitudinal quasi-experimental between-groups design PARTICIPANTS: Eighty-five MTBI subjects aged between 16 and 65 years SETTING: The emergency ward of the Trois-Rivieres Regional Hospital Centre in Quebec, Canada MAIN OUTCOME MEASURES: Age, gender, Glasgow Coma Scale score, duration of posttraumatic amnesia, duration of retrograde amnesia, total of symptoms at emergency, time elapsed since the trauma, Paced Auditory Serial Addition Task, Stroop Color Word Test, California Verbal Learning Test, and the number of symptoms at follow-up (12 to 36 months posttrauma) RESULTS: Only the total number of symptoms reported at follow-up was related to vocational status The majority of individuals had returned to work 1 year or more post-MTBI Individuals who had not returned to work reported the greatest number of symptoms, which could be linked to their affective status Six affective symptoms, 5 cognitive symptoms, 6 physical symptoms, and 8 symptoms relating to social and daily life activities differentiated the participants who had returned to work from those who had not CONCLUSIONS: Patient characteristics, injury severity indicators, and cognitive functions were not associated with vocational status To better understand post-MTBI vocational status, it is important to focus on subjective complaints that arise following the injury Language: en
TL;DR: After TBI, patients at the greatest risk for distress at follow-up were those with family dysfunction at discharge and continued neurobehavioral problems.
Abstract: OBJECTIVE To identify risk factors for poor family functioning and neurobehavioral problems after traumatic brain injury (TBI) or orthopedic injuries (OI). DESIGN Longitudinal analyses of data from an inception cohort. PARTICIPANTS Seventy-five patients with moderate/severe TBI, 47 patients with mild TBI, and 44 patients with OI at discharge; and 49 patients with moderate/severe TBI, 24 patients with mild TBI, and 33 patients with OI at 1-year follow-up. OUTCOME MEASURES Measures of family functioning (Family Assessment Device) and Neurobehavioral Functioning Index at hospital discharge and 1-year follow-up. RESULTS At discharge, patients with moderate/severe TBI had more symptoms of depression, memory/attention problems, and motor impairments than patients with OI and greater communication difficulties than patients with OI or mild TBI. At follow-up, patients with moderate/severe TBI continued to have more problems in memory/attention, depression, and communication. Approximately one third of each group had unhealthy family functioning at each assessment period. Few patients reported both impaired family functioning and clinical depression. Distressed family functioning correlated strongly with increased rates of neurobehavioral symptoms. Family dysfunction at follow-up was best predicted by family dysfunction at discharge and depression or memory/attention deficits at follow-up. CONCLUSIONS After TBI, patients at the greatest risk for distress at follow-up were those with family dysfunction at discharge and continued neurobehavioral problems. High-risk families need to be identified so that necessary referrals and/or treatment can be offered.
TL;DR: More severe brain injury is associated with fewer friends in the postacute phase following TBI, and broadening the social network of children with moderate and severe TBI should be a major goal of neuropsychological rehabilitation.
Abstract: OBJECTIVE: To determine whether a dose-response relation exists between the number of reported close friends and traumatic brain injury (TBI) severity in the postacute phase in school-age children. DESIGN: A retrospective relational study. SETTING AND PARTICIPANTS: Primary care hospital/medical center-based study on parental perspectives of recovery following TBI in school-age children (14 with severe TBI; 10 with moderate TBI; 36 with mild TBI; and 16 trauma controls). MAIN OUTCOME MEASURES: Parental ratings on the Child Behavior Checklist and selected neuropsychological test findings and ratings of academic performance. RESULTS: Seventy-five percent of trauma controls but only 38.9% of children with mild and 20% of children with moderate TBI reportedly had 4 or more friends. Only 14.3% of children with severe TBI reportedly had 4 or more friends. Glasgow Coma Scale score at admission correlated with the number of friends postacutely (by parental reports) (r = +0.307, N = 76, P = .007). CONCLUSION: More severe brain injury is associated with fewer friends in the postacute phase following TBI. The relation, however, was not purely linear and the hypothesis was supported only partially. Broadening the social network of children with moderate and severe TBI should be a major goal of neuropsychological rehabilitation. Language: en
TL;DR: Testable, theoretically motivated interventions at 2 levels are described: the goal level focused on attaining or enhancing performance on individual tasks and the self-regulation level of metacognitive processes involved in planning and managing one's own goal-directed behavior.
Abstract: Goal planning is a central concept in the clinical practice of rehabilitation. Several disciplines within psychology and medicine have elaborated theories related to goal attainment and self-regulation, the process of managing one's own goal-directed behavior. These theories may be highly relevant to brain injury rehabilitation both to help address characteristic deficits in executive function and to teach clients how to manage life tasks outside of formal rehabilitation. In this article, we describe testable, theoretically motivated interventions at 2 levels: the goal level focused on attaining or enhancing performance on individual tasks and the self-regulation level of metacognitive processes involved in planning and managing one's own goal-directed behavior. We also discuss issues in experimental methodology that are important to adapting this area of research to brain injury rehabilitation, including consideration of cognitive status and other individual differences in selecting the participant sample, choice of between-subjects versus within-subjects experimental design, and selection of appropriate outcome measures.
TL;DR: A multivariate model of the dynamic interactions among key variables associated with relative distress and disrupted family functioning after traumatic brain injury highlights the impact on families when the person with TBI experiences restrictions in participation.
Abstract: Objectives: To develop a multivariate model of the dynamic interactions among key variables associated with relative distress and disrupted family functioning after traumatic brain injury (TBI). Participants: A relative sample (parents, spouses, close others; n = 134) derived from a statewide cohort of people with TBI recruited to the multicenter Brain Injury Outcomes Study. Setting: A consecutive series of referrals over a 2-year period to the 11 adult units of the Brain Injury Rehabilitation Program in New South Wales, Australia. Main Outcome Measures: Relative measures included General Health Questionnaire-28 (psychological distress), Family Assessment Device (family functioning), and BIOS Family Needs Questionnaire (perceived adequacy of support). The degree of impairment and level of participation of the person with TBI were assessed by the Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale, respectively. Analysis: Path analysis examined the varying contribution of impairment, participation, and support variables to both relative distress and disturbances in family functioning. Results: The overall model accounted for substantial proportions of the variance in psychological distress and family functioning. Importantly, the distress experienced by relatives was not due to the direct impact of the neurobehavioral impairments, but the effect of these impairments was mediated by the degree of community participation achieved by the person with TBI. Conclusions: The model highlights the impact on families when the person with TBI experiences restrictions in participation. Clinically, a greater focus on the provision of respite or case management services may assist in reducing relative distress.
TL;DR: The results confirm IAD's link to treatment adherence, and support the observation that IAD is a common clinical feature of brain injury that should be carefully considered when making prognoses and developing and applying interventions with this population.
Abstract: OBJECTIVE To examine the relation between impaired awareness of deficits (IAD) and treatment adherence and to verify previous findings regarding the types of disabilities that people with traumatic brain injury (TBI) tend to underestimate. DESIGN Cross-sectional study. PARTICIPANTS Twenty-four persons with moderate to severe TBI and 16 persons with traumatic spinal cord injury (SCI) admitted to an inpatient neurorehabilitation program. MAIN OUTCOME MEASURES IAD assessed using the short version of the Problem Checklist of the Head Injury Family Interview and treatment adherence using the Medical Regimen Adherence Scale. RESULTS Presence of IAD is linked with poor adherence. Patients with TBI significantly underestimate their emotional/behavioural and cognitive disabilities, but accurately assess their physical disabilities, whereas patients with SCI accurately assess all spheres. Patients with TBI are significantly less aware of their disabilities compared with the patients with SCI as expected. CONCLUSIONS These results confirm IAD's link to treatment adherence, and support the observation that IAD is a common clinical feature of brain injury that should be carefully considered when making prognoses and developing and applying interventions with this population.
TL;DR: In this article, a review of neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS are presented.
Abstract: Advances in neuroimaging techniques hold significant promise for improving understanding of disorders of consciousness arising from severe brain injuries. We review neuroimaging studies of the vegetative state (VS) and minimally conscious state (MCS), and findings in an unusual case of late emergence from MCS. Multimodal neuroimaging studies using positron emission tomography techniques, functional magnetic resonance imaging, and quantitative electroencephalography and magnetoencephalography quantify variations of residual cerebral activity across these patient populations. The results suggest models to distinguish the pathophysiologic basis of VS and MCS. Less clear are potential brain mechanisms underlying late recovery of communication in rare MCS patients. Diffusion tensor magnetic resonance imaging studies and recent experimental findings suggest that structural remodeling of the brain following severe injury may play a role in late functional recoveries. More generally, relatively long time courses of recovery following severe brain injury emphasize the need to develop markers for identifying patients who may harbor potential for further meaningful recovery. Introduction of neuroimaging into the clinical evaluation process will require developing frameworks for longitudinal assessments of cerebral function. Although limited in number, available studies already provide important insights into underlying brain mechanisms that may help guide development of such assessment strategies.
TL;DR: A theory-based model for the treatment of post–traumatic brain injury executive dysfunction is proposed that integrates theories of cerebral function and organization, cognitive-behavioral theory of problem solving, and learning theory.
Abstract: The authors propose a theory-based model for the treatment of post-traumatic brain injury executive dysfunction that integrates (1) theories of cerebral function and organization, (2) cognitive-behavioral theory of problem solving, and (3) learning theory. The model delineates appropriate targets of and methods for the treatment of executive dysfunction. A practical application of the theoretical model is described in the form of a comprehensive day treatment program, Executive Plus. A test of the model is also discussed, focused on the comparison of Executive Plus and a standard day treatment program along parameters dictated by the model.
TL;DR: It is concluded that although genetic advances have implications for prognosis, their biggest contribution will be to elucidate the pathophysiology of TBI, potentially leading to new treatments.
Abstract: It is becoming increasingly clear that genetic factors modify outcome after traumatic brain injury (TBI). The best known example of this is the association between the apolipoprotein E4 allele (APOE epsilon4) and poorer outcomes. However, our knowledge of the many other genes that might influence outcome is still in its infancy. This article will review the basic principles underlying recent advances in genetics, and then describe the current state of knowledge regarding the impact of genetic factors on TBI outcome. We conclude that although genetic advances have implications for prognosis, their biggest contribution will be to elucidate the pathophysiology of TBI, potentially leading to new treatments.
TL;DR: The technology of MRS is reviewed, its role in patient assessment after traumatic brain injury is discussed, and a summary of the published and ongoing research is presented.
Abstract: Proton magnetic resonance spectroscopy (MRS) is being used to evaluate individuals after acute traumatic brain injury. These studies have shown that changes in certain brain metabolites are associated with poor neurologic outcomes. The majority of MRS studies have been obtained relatively late after injury, but there have been a few reports of use early after injury to assist with outcome prediction. Altered brain metabolites may be sensitive indicators of injury and thus provide additional prognostic information when spectroscopy is done early after injury. This technology may provide a noninvasive means to evaluate early excitotoxic injury, and show changes associated with both neuronal injury and membrane disruption secondary to diffuse axonal injury. This article will review the technology of MRS, discuss its role in patient assessment after traumatic brain injury, and present a summary of our published and ongoing research.
TL;DR: Population-based outcome studies that describe longer term problems associated with TBI, the need for services, and estimated disability could be useful to inform public policy.
Abstract: OBJECTIVE: To describe the design and operations of the South Carolina Traumatic Brain Injury (TBI) Follow-up Registry. DESIGN: Statewide prospective cohort study. SETTING: State of South Carolina. PARTICIPANTS: 2118 persons discharged from acute care hospitals after experiencing TBI. INTERVENTION: Telephone interviews. MAIN OUTCOME MEASURES: Service needs, alcohol and drug use, psychosocial health, health-related quality of life, functional status, symptoms of TBI, employment, global life satisfaction, and death. RESULTS: Selected initial and 1-year follow-up findings concerning demographic, insurance status, income, and employment factors. CONCLUSIONS: Population-based outcome studies that describe longer term problems associated with TBI, the need for services, and estimated disability could be useful to inform public policy. Language: en
TL;DR: A theoretical framework is presented that generates hypotheses regarding the effects of training on the functional integration of processes across distributed networks of brain regions that may guide cognitive rehabilitation and facilitate development of adjunctive biologic treatments to enhance the results of training.
Abstract: Functions of the prefrontal cortex (PFC) are fundamental to learning and rehabilitation after brain injuries, but the PFC is particularly vulnerable to trauma. We propose approaches to cognitive training that are hypothesized to specifically enhance PFC function. We present a theoretical framework that generates hypotheses regarding the effects of training on the functional integration of processes across distributed networks of brain regions. Specific outcome measurements that may be used to test these hypotheses in clinical trials are proposed. This neural network-level approach may guide cognitive rehabilitation and facilitate development of adjunctive biologic treatments to enhance the effects of training.
TL;DR: A comprehensive review of recently generated research knowledge in the field of TBI has shown that a large number of Class III and IV evidence studies have been published, but relatively few of the more scientifically rigorous Class I or II studies.
Abstract: In 1998, an NIH sponsored Consensus Conference on Traumatic Brain Injury (TBI) Rehabilitation identified 30 different areas of needed research. A comprehensive review of recently generated research knowledge in the field of TBI has shown that a large number of Class III and IV evidence studies have been published, but relatively few of the more scientifically rigorous Class I or II studies. A rapid growth of publications on TBI rehabilitation has generated new knowledge in the epidemiology of TBI, the management of TBI and its secondary medical complications, rehabilitation of cognitive impairment, impact of TBI on community integration and quality of life, incidence of psychiatric dysfunction, and how caregivers and family members are affected. However, there is need to replicate many of these studies using more scientifically rigorous methodologies, while other areas of important TBI research remain largely unexplored.
TL;DR: The principles of transcranial magnetic stimulation are outlined, the existing use of TMS as a prognostic indicator and as a therapeutic device in clinical populations are summarized and the potential of repetitive TMS (rTMS) as an intervention for traumatic brain injury is highlighted.
Abstract: The purpose of this article is to outline the principles of transcranial magnetic stimulation (TMS), to summarize the existing use of TMS as a prognostic indicator and as a therapeutic device in clinical populations, and to highlight the potential of repetitive TMS (rTMS) as an intervention for traumatic brain injury. TMS is a painless method to stimulate the human brain. Repeated applications of TMS can influence brain plasticity and cortical reorganization through stimulation-induced alterations in neuronal excitability. Existing evidence has demonstrated positive outcomes in people with motor disorders and psychiatric conditions who have received rTMS as a therapeutic intervention. These findings suggest that rTMS may be a promising treatment for people with traumatic brain injury.
TL;DR: Short- and middle-latency evoked potentials can now effectively predict coma outcomes in patients with acute TBI and hold promise in predicting recovery of higher order cognitive abilities.
Abstract: Clinicians are often expected to project patients' clinical outcomes to allow effective planning for future care. This can be a challenge in patients with moderate to severe traumatic brain injury (TBI) who are often unable to participate reliably in clinical evaluations. With recent advances in computer instrumentation and signal processing, evoked potentials and event-related potentials show increasing promise as powerful tools for prognosticating the trajectory of recovery and ultimate outcome from the TBI. Short- and middle-latency evoked potentials can now effectively predict coma outcomes in patients with acute TBI. Long-latency event-related potential components hold promise in predicting recovery of higher order cognitive abilities.
TL;DR: Treatment theories shape inclusion and exclusion criteria by suggesting what types of patients may benefit, and shape outcome measures by suggesting where the treatment impact should be seen.
Abstract: Many rehabilitation treatments are difficult to define, resulting in a lack of clarity about their essential "active ingredients." Treatment theories can narrow the scope of possible active ingredients, by clearly specifying how the treatment is believed to act. Efficacy studies of theory-defined treatments assess their clinical value, but also advance the science underlying the theory. In addition, treatment theories shape inclusion and exclusion criteria by suggesting what types of patients may benefit, and shape outcome measures by suggesting where the treatment impact should be seen. Finally, treatment theories can assist an investigator in the selection of an optimal study design.
TL;DR: Participants with MTBI showed a significant deficit in free recall on the California Verbal Learning Test but performed similarly to the comparison group on the recognition task, which supports the initial hypothesis that executive dysfunctions are detrimental to the quality of mnemonic functions in patients withMTBI.
Abstract: OBJECTIVES To explore the contribution of executive dysfunctions to mnemonic problems in adults with mild traumatic brain injury (MTBI). DESIGN Prospective quasiexperimental between-groups design. PARTICIPANTS Ninety-nine persons with MTBI were compared to 90 control group participants matched for gender, age, and education. SETTING Two Canadian brain injury rehabilitation programs. MAIN OUTCOME MEASURE California Verbal Learning Test. RESULTS Participants with MTBI showed a significant deficit in free recall on the California Verbal Learning Test but performed similarly to the comparison group on the recognition task. Furthermore, the participants with MTBI were less likely to use semantic clustering as a memorizing strategy and made more intrusion errors and false-positive errors on the recognition task. CONCLUSIONS While the scores for the participants with MTBI are only slightly lower than the norm, they demonstrate that MTBI has a negative effect on mnemonic performance. The results are explained in terms of a deficit in registration/retrieval processes rather than a malfunction of the storage processes. This supports the initial hypothesis that executive dysfunctions are detrimental to the quality of mnemonic functions in patients with MTBI.
TL;DR: The association between decreased motoricity index and decreased FA suggests that DTI may be useful in evaluating patients with traumatic brain injury, and fractional anisotropy of the corticospinal tract may be used in the detection of diffuse axonal injury.
Abstract: OBJECTIVES To determine whether diffusion tensor imaging (DTI) can detect diffuse axonal injury, and to evaluate the association of DTI findings with motor function in patients with traumatic brain injury. DESIGN Three case studies. SETTING An inpatient rehabilitation unit in Korea. PARTICIPANTS Three patients with traumatic brain injury in whom conventional neuroimaging showed normal-appearing white matter. MAIN OUTCOME MEASURES Patients were studied with DTI. Fractional anisotropy (FA) was measured from 3 different anatomic locations on both sides of the corticospinal tract. Motor function was evaluated using the motoricity index. RESULTS Fractional anisotropy tended to be reduced in normal-appearing corticospinal tracts that were remote from the involved segment. Diffusion tensor imaging showed reduction of FA in areas consistent with motor dysfunction. CONCLUSION Fractional anisotropy of the corticospinal tract may be used in the detection of diffuse axonal injury. The association between decreased motoricity index and decreased FA suggests that DTI may be useful in evaluating patients with traumatic brain injury.
TL;DR: This study evaluated 2 alternative approaches to treatment: one focusing on underlying cognitive processes and the second on errorless learning in everyday functional situations, both of which were based on the Defense and Veterans Brain Injury Center cognitive-didactic versus functional-experiential study methodology.
Abstract: This is a descriptive article outlining issues in the development and implementation of a multisite randomized rehabilitation trial for brain injury treatment. The goal of this article is to present practical and theoretical considerations in designing and conducting multicenter rehabilitation trials. Practical issues discussed include (a) treatment setting, (b) patient accessibility in determining the research question of interest, as well as inclusion and exclusion criteria, (c) research protocol development in the context of rehabilitation standard of care, and (d) protocol treatments in the context of realistic cost-benefits analysis. Rehabilitation theory is discussed as playing an important role designing the specifics of the protocol interventions. The Defense and Veterans Brain Injury Center Veterans Health Administration cognitive-didactic versus functional-experiential study methodology is used for illustrative purposes. This study evaluated 2 alternative approaches to treatment: one focusing on underlying cognitive processes and the second on errorless learning in everyday functional situations. Lessons learned over the course of completing the treatment trial are discussed.