Subjective reports of fatigue during early recovery from traumatic brain injury.

OBJECTIVE: To determine whether patients with traumatic brain injury (TBI) report higher levels of fatigue than do normal controls and to identify demographic and cognitive correlates of self-reported fatigue. DESIGN: Prospective study. SETTING: Inpatient neurorehabilitation unit in a medical center and neurological institute. PARTICIPANTS: Forty-seven neurorehabilitation inpatients with TBI. MAIN OUTCOME MEASURES: Barrow Neurological Institute (BNI) Fatigue Scale and BNI Screen for Higher Cerebral Functions. RESULTS: Patients reported significantly greater levels of fatigue compared to the levels reported by normal controls, although fatigue was found to be unrelated to injury severity, number of days from injury to assessment, cognitive impairment, and gender. Inspection of individual items revealed no significant differences between severe versus moderate versus mild TBI groups. However, being able to last the day without taking a nap (ie, item 10) was found to be the most sensitive item associated with fatigue in the TBI group. CONCLUSIONS: Results of this study suggest the need to integrate activities and interventions to increase endurance in patients with TBI during early rehabilitation. Accommodating regular rest breaks and increasing restful sleep should be a focus of inpatient neurorehabilitation units.

Awareness and distress after traumatic brain injury: a relative's perspective.

OBJECTIVE: To examine the relationship between relatives' distress level and their ratings of impaired awareness for persons with traumatic brain injury (TBI). DESIGN AND OUTCOME MEASURES: Participants were 25 patients with TBI, 16 with probably dementia, and 15 with memory complaints but no dementia. Participants completed the Barrow Neurological Institute Screen for Higher Cerebral Functions. Relatives of all patients completed the Patient Competency Rating Scale (Relative Form). Relatives also rated their distress level on a scale from 0 (no distress) to 10 (severe distress) and then rated the patient's level of awareness of their difficulties, also on a scale from 0 (not aware) to 10 (completely aware). SETTING: Clinical neuropsychology outpatient service of a neurological institute and medical center. RESULTS: For relatives of patients with TBI, a significant correlation of -0.52 (P = .006) was found. Correlations for the dementia and memory complaint groups were -0.62 (P = .03) and -0.39 (P = .20), respectively. CONCLUSIONS: The presence of brain dysfunction associated with neuropsychological disturbances appears to influence the magnitude of the relationship between the distress level of family members and their ratings of impaired awareness in persons with TBI.

Fatigue after brain injury: initial reliability study of the BNI Fatigue Scale.

OBJECTIVE: Fatigue is a common problem of many neurological disorders. Yet, few measures have been developed to adequately assess fatigue, particularly during the early stages following a brain injury. The purpose of this study was to document the psychometric properties of the BNI Fatigue Scale for use on an acute, inpatient neurorehabilitation unit. RESEARCH DESIGN: A prospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: The BNI Fatigue Scale was administered to an heterogeneous sample of 84 neurologic patients upon admission to the Neurorehabilitation unit within 20 days of their injury. RESULTS: Principle components factor analysis yielded a one-factor solution. Acceptable internal consistency was calculated for the scale items. Overall index of fatigue correlated significantly with the total scale score. CONCLUSIONS: This initial study on the BNI Fatigue Scale supports its reliability and clinical utility for use with acute neurological patients. Information obtained by this scale may help to guide the rehabilitation process and provide direction for intervention and treatment.

Disturbances in affective communication following brain injury.

PRIMARY OBJECTIVE: Disturbances in affect expression and perception are often clinically observed in brain injured patients during the acute stages of recovery. This study examined whether such disturbances are related to the acute nature of the injury or specific type of injury in patients with stroke (CVA) versus traumatic brain injury (TBI). RESEARCH DESIGN: Retrospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: Participants were 27 CVA and 27 TBI patients. Their performance was compared to 27 normal controls on the BNI Screen for Higher Cerebral Functions. OUTCOMES AND RESULTS: While both patient groups performed significantly worse than the control group on affect expression, perception and spontaneity (p<0.01), the CVA group performed significantly worse than the TBI group (p<0.01) on affect perception. Results of this study document disturbances in affect in brain injured patients and highlight the importance of assessing affect during early recovery.

Modification of the Patient Competency Rating Scale for use on an acute neurorehabilitation unit: the PCRS-NR.

OBJECTIVE: The Patient Competency Rating Scale (PCRS) is a 30-item self-report questionnaire that was developed to assess awareness of deficits in post-acute patients following traumatic brain injury (TBI). The purpose of this study was to develop a modified and psychometrically sound version of the PCRS for use on an acute, inpatient neurorehabilitation unit. RESEARCH DESIGN: Prospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: Nineteen items from the original PCRS were retained for their applicability to an inpatient neurorehabilitation unit and administered to 108 acute neurological inpatients. RESULTS: Principle components factor analyses with varimax rotation yielded a three factor solution.Acceptable internal consistencies were calculated for each factor and the total PCRS score. CONCLUSIONS: These findings document the psychometric properties of a briefer version of the PCRS for use on an inpatient rehabilitation unit. This modified version has been labelled the PCRS for neurorehabilitation (i.e. PCRS-NR).

The use of the BNI screen for higher cerebral functions in assessing disorientation after traumatic brain injury.

OBJECTIVE: To examine the use of the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) in assessing disorientation in patients with traumatic brain injury (TBI) during the acute phases of rehabilitation. DESIGN: Persons with TBI (n = 65) were compared with patients with spinal cord injury (SCI; n = 18) and to controls (n = 35). SETTING: Inpatient neurorehabilitation unit. OUTCOME MEASURES: Orientation items from the BNIS measuring time (day, month, date of month, year) and place (city and hospital). RESULTS: TBI patients showed a significantly greater proportion of incorrect responses to time and place compared with the SCI and normal control groups. There was a greater accuracy on orientation to place compared with orientation to time, and date of month produced the lowest rate of accuracy in all three groups. The single best predictor of disorientation to time was increasing age, and increasing age was most associated with disorientation to date of month. CONCLUSIONS: The BNIS was shown to be a sensitive measure of disorientation in TBI patients and yielded similar patterns of performance as documented by other measures.

The Patient Distress Scale questionnaire: factor structure and internal consistency.

PRIMARY OBJECTIVE: This study examined the factor structure and internal consistency of the Patient Distress Scale (PDS). The PDS is an 11-item questionnaire that was developed to assess acute neurological patients' awareness of emotional disturbances during early rehabilitation. RESEARCH DESIGN: A retrospective cohort of patients seen for inpatient rehabilitation following brain injury. PROCEDURES: The PDS was administered to patients and family members upon admission to the neurorehabilitation unit as part of their neuropsychological evaluation. OUTCOMES AND RESULTS: Subjects were heterogeneous sample of acute neurological inpatients (n = 84) and their relatives (n = 64). A principle components factor analysis with varimax rotation yielded a three factor solution, which together accounted for 62% of the variance. The factor solution provided partial support for the initial structure of the PDS. Analyses revealed relatively strong reliability coefficients for patients (r = 0.82) and relatives (r = 0.86) on the PDS total score. Acceptable reliability coefficients were also found for patients and relatives on each of the factor scores. CONCLUSIONS: Preliminary findings support the utility of the PDS as a measure of awareness in acute neurological patients.

Convergence of different versions of the continuous performance test: clinical and scientific implications.

The Continuous Performance Test has been used for the last 40 years to measure sustained attention or vigilance in many different populations. Different versions of the test have been developed, but little is known about how similar these tests are, and to what extent performance on different versions of these tests overlaps. In order to examine convergence of the different versions of the CPT, three different CPTs were administered in both the Auditory and Visual Sensory Modalities. Subjects were selected from consecutive admissions to adolescent acute care units at a private psychiatric hospital (n=100). Auditory test modalities uniformly elicited poorer performance than visual tests, while each set of task demands consistently elicited differences in performance. Despite the high test-retest reliability of the individual subtests, the average correlation between tests was r=.42, with the average correlation between visual tests at r=.48 and the average correlation between the auditory tests was r=.45. The correlations within task demands across sensory modalities ranged from a low of.37 to a high of.52. Controlling for IQ did not influence the correlations to a substantial degree. These data suggest different versions of the CPT are correlated with each other at a level consistent with construct validity, but that they do not constitute alternate forms of the same test.

Cognitive and affective sequelae in complicated and uncomplicated mild traumatic brain injury.

This study examined cognitive and affective disturbances in patients with complicated (presence of space occupying lesion) vs uncomplicated (absence of space occupying lesion) mild traumatic brain injury (TBI). It was predicted that the complicated group would perform worse in both domains compared to the uncomplicated group. Participants were 28 patients admitted to an inpatient neurorehabilitation unit with mild TBI and assessed within 40 days of their injury. The complicated group (n = 14) was matched to the uncomplicated group (n = 14) on Glasgow Coma Scale score and compared to 14 normal controls on the BNI Screen for Higher Cerebral Functions (BNIS). The complicated group showed greater cognitive disturbances than the uncomplicated and control groups, while both TBI groups performed worse on affective measures. These findings document the role of affective disturbances in mild TBI. They also highlight the importance of early intervention strategies for improving affective communication in patients with mild TBI.

Qualitative features of finger movement during the Halstead finger oscillation test following traumatic brain injury.

Qualitative and quantitative performance on the Halstead Finger Tapping test may help differentiate brain dysfunctional patients from normal controls. "Normal" and "abnormal" finger tapping patterns during this task have been characterized and illustrated pictorially. Data from 65 patients with traumatic brain injury (TBI) and 15 normal controls support the dual proposition that (1) abnormal finger tapping patterns are more commonly observed in TBI patients than in controls and (2) the frequency of abnormal finger movements may relate to the severity of TBI during the acute stages after trauma. Future prospective studies are needed to replicate these findings.

Non-pharmacological management of psychiatric disturbances after traumatic brain injury.

Persons who suffer traumatic brain injury (TBI) often demonstrate a variety of psychiatric and neuropsychiatric disturbances. Some of those disturbances may be managed by non-pharmacological methods. The methods draw heavily on established principles of psychotherapy and behavioral modification. However, the unique problems imposed by neurocognitive deficits must be factored into any form of non-pharmacological intervention with this patient group. A simple model consolidates information about the important ingredients in the non-pharmacological management of psychiatric disturbances in TBI patients.

Verbal IQ-performance IQ differentials in traumatic brain injury samples.

Several studies of head trauma utilizing the Wechsler Adult Intelligence Scale (WAIS) reported large sample differentials between verbal IQ (VIQ) and performance IQ (PIQ), leading some writers to claim that the VIQ is largely unaffected by traumatic brain injury (TBI), and that a superiority of VIQ over PIQ should be expected. In contrast, our review of Wechsler Adult Intelligence Scale-Revised (WAIS-R) studies indicates that although TBI sample PIQ means are often depressed relative to VIQ means, the differences are small and sometimes in the opposite direction. Possible reasons for the discrepancy between our WAIS-R review and those of an earlier review of WAIS studies are discussed. Clinically, the lack of a VIQ-PIQ difference should never be used to infer that a TBI has not occurred.

Early cognitive and affective sequelae of traumatic brain injury: a study using the BNI Screen for Higher Cerebral Functions.

OBJECTIVE: To demonstrate that the Barrow Neurological Institute (BNI) Screen for Higher Cerebral Functions (BNIS) can be used to briefly assess cognitive and affective disturbances during the acute stages after traumatic brain injury (TBI). DESIGN AND OUTCOME MEASURES: People with TBI were administered the BNIS during the first 60 days after injury and their performance compared to a convenience sample of control subjects used in the standardization of the BNIS. SETTING: Inpatient units of a neurological institute and medical center. SUBJECTS: Forty-two individuals with moderate-to-severe TBI and 21 control subjects. RESULTS: Compared to patients with TBI, control subjects performed significantly better on the BNIS total and all subtest scores. TBI patients were best classified by poor performance on measures of affect disturbance and impaired awareness. Stepwise discriminant analysis identified disturbances in memory, awareness, and affect as contributing most to the classification of an individual as having TBI. CONCLUSIONS: Both cognitive and affective disturbances can be directly assessed during the early stages after significant TBI. The BNIS can be used for this purpose and help document that TBI specifically affects memory, awareness, and affect during its early stages and should be addressed in rehabilitation.