Assessing risk and harm: the convergence of ethical and empirical considerations.

Neurorehabilitation clinicians are frequently asked to make clinical predictions of risk and harm in cases where persons with brain injury are believed to be unable or unsafe to conduct normal activities of daily living. Because predictions of risk and harm may ultimately limit a brain-injured person's autonomy, clinical decision makers should be aware of the ethical and empirical issues involved in such determinations. Constraining autonomy can be an ethical problem even when clinicians are apparently acting in patients' best interests. Clinicians must consider their ability to make accurate risk and harm predictions based on clinical data. Clinicians who are aware of contemporary ethical principles will be most prepared to integrate ethical and empirical considerations when determining risk and harm.

Head injury--a survey of current practices in preventive health care counselling.

OBJECTIVES: This study examined whether primary care physicians provide education and counselling on head injury prevention as part of their routine health care discussions with patients. METHODS: A preventive health care practices survey was distributed to 678 physicians in the Central Virginia area. Data regarding respondents' age, gender, medical specialty, patient population and counselling practices were obtained. RESULTS: Fifty-one per cent of those surveyed responded. Ninety-five per cent of physicians reported providing health care counselling 'in most cases' or 'commonly'. Less than half (46%) of physicians discussed head injury prevention with their patients. In contrast, almost all respondents (97%) discussed smoking. Physician age, specialty, and patient population did not affect head injury counselling practices. CONCLUSIONS: Prevention strategies for head injury are discussed much less frequently than other health risks such as heart disease and cancer in the primary care setting. Strategies for educating primary care physicians on head injury should be considered in order to increase their efforts toward prevention.

Ischemic stroke: relation of age, lesion location, and initial neurologic deficit to functional outcome.

OBJECTIVE: Establish the relation between age, gender, initial neurologic deficit, stroke location, prior stroke, hemisphere of stroke, and functional outcome in ischemic stroke. DESIGN: Single group, multivariate, repeated measures design with 327 persons having ischemic stroke recruited from 20 participating centers. SETTING: Twenty European stroke centers. PATIENTS: Consecutive admissions of men and women between the ages of 40 and 85 yrs with a hemispheric stroke caused by middle cerebral artery ischemia and a Unified Neurological Stroke Scale score of 5 to 24. INTERVENTIONS: Inpatients enrolled in the trial received traditional rehabilitation therapies including physical therapy, occupational therapy, and speech therapy when appropriate. MAIN OUTCOME MEASURES: Barthel Index computed at 7 to 10 days and 3 months poststroke. RESULTS: Positive functional outcomes were significantly related to the absence of prior strokes, a younger age, a less severe initial neurologic deficit, stroke involving cortical structures, and dominant (left hemisphere) lesions. CONCLUSIONS: Despite some inconsistencies in existing literature, standardized prospective examination of outcome after stroke clearly demonstrated the effect of age, initial severity of stroke, and lesion location as predictors of functional outcome.

Outcome after mild head injury.

Although concern about mild sports head injury has significantly increased in the past decade, few well-controlled studies exist. As such, we are not able to definitively specify the effect of injury biomechanics, severity, frequency, and complications on outcome. Until more definitive research is completed, management of mild head injury will have to be based on clinical judgment rather than empiric fact. Despite present empiric limitations, several tentative conclusions appear appropriate. First, head injury is a relatively frequent occurrence in sports. Second, the overwhelming majority of single, grade 1 injuries have few persisting symptoms, and morbidity in the short-term appears low. Third, multiple injuries (> 3), especially grade 2 or grade 3, may have long-term irreversible consequences. Fourth, as best as we can tell, athletes with apparently equivalent injuries by clinical standards may have different outcomes. Finally, outcome in mild sports head injury must receive increased research attention, and some symmetry and coordination of efforts should be encouraged.

Neurorehabilitation outcome in moyamoya disease.

Moyamoya is a disease characterized by occlusion of the internal carotid, anterior, and middle cerebral arteries with associated rich collateral flow that presents a cloudy appearance on angiogram resembling a puff of smoke. The disease is most often progressive with associated hemiparesis and cognitive impairment. The functional outcome of patients with moyamoya is not well described in the literature. We describe four women (ages 25-36) who were transferred to a rehabilitation service after an average 17 days (12-26 days) in an acute care setting. Initial functional impairment was estimated using the Functional Independence Measure (FIM) score after discharge from inpatient rehabilitation (23-53 days) and was compared to the Uniform Data System for Medical Rehabilitation (UDSMR) for "first stroke" patients. Average admission FIM scores were similar in the two groups. The patients with moyamoya had a higher discharge FIM, longer length of stay, and slower rate of progress. Data on long-term survival and functional level would be useful, but it appears patients with moyamoya disease may benefit from rehabilitation oriented toward neurological deficits.

Predictive power of clinical symptoms in patients with presumptive deep venous thrombosis.

The predictive power of clinical symptoms in the diagnosis of deep venous thrombosis (DVT) was assessed using a retrospective design. The sample consisted of 61 rehabilitation patients who were referred for Doppler ultrasonography. Patients had a mean age of 60.6 (standard deviation, 18.4) years. Clinical measures documenting presence of swelling, warmth, fever, and lower limb asymmetry (> 2.5 cm) were correlated with the outcome of venous duplex Doppler examinations. Clinical symptoms had low sensitivity (0.07-0.33) but generally higher specificity (0.76-0.85) for DVT. Positive predictive power was lowest for fever (0.08) and highest for swelling (0.66). Prevalence rates for DVT were greatest (0.41) in patients presenting with multiple symptoms. Results suggest clinical predictors of DVT remain elusive. A high rate of false-positives based on clinical findings from examination is acceptable given the low risk associated with ultrasonography and the clear benefit of early diagnosis of DVT.

Ethical considerations in neuroclinical trials.

Ethical decision making in clinical trials has become increasingly emphasized at many levels of the review process. Ethical concepts applicable to Neuroclinical Trials (NCT) are reviewed. The discussion is directed towards ethical concerns that investigators must consider and justify prior to Institutional Review Board (IRB) submission. Risk-benefit analysis, methodology (randomization: placebo; design) and consent (informed; deferred; waived) are reviewed and Office for Protection from Research Risk (OPRR) guidelines are described. Our conclusions: Investigators proposing NCT face increasing ethical scrutiny by IRBs. Attention to ethical issues early in trial planning process is recommended.

Ethical considerations in clinical neuroscience. Current concepts in neuroclinical trials.

BACKGROUND: Ethical decision making in clinical trials has become increasingly emphasized at many levels of the review process. SUMMARY OF REVIEW: Ethical concepts applicable to neuroclinical trials are reviewed. The discussion is directed toward ethical concerns that investigators must consider and justify prior to institutional review board submission. Risk-benefit analysis, methodology (randomization, placebo, design), and consent (informed, deferred, waived) are reviewed and guidelines of the Office for Protection From Research Risk are described. CONCLUSIONS: Investigators proposing neuroclinical trials face increasing ethical scrutiny by institutional review boards. Attention to ethical issues early in the trial planning process is recommended.

Neuropsychological functioning and recovery after mild head injury in collegiate athletes.

OBJECTIVE: This study prospectively examined neuropsychological functioning in 2300 collegiate football players from 10 National Collegiate Athletic Association Division A universities. The study was designed to determine the presence and duration of neuropsychological symptoms after mild head injury. METHODS: A nonequivalent repeated measures control group design was used to compare the neuropsychological test scores and symptoms of injured players (n = 183) with those of gender, age, and education matched controls. A number of neuropsychological tests, including the Paced Auditory Serial Addition Test, the Digit Symbol Test, and the Trail Making Test, as well as a symptom checklist were used. TECHNIQUE: Players and controls were assessed before engaging in game activity and 24 hours, 5 days, and 10 days after injury, using the standardized test battery and symptom checklist. RESULTS: Players with head injuries displayed impaired performance and increased symptoms in comparison to controls, but this impairment resolved within 5 days in most players. Players with head injuries showed significant improvement between 24 hours and 5 days, as well as between 5 and 10 days. CONCLUSION: Although single, uncomplicated mild head injuries do cause limited neuropsychological impairment, injured players generally experience rapid resolution of symptoms with minimal prolonged sequelae.

Effect of cognitive impairment on rehabilitation outcome.

Previous studies examining the relationship between cognition and ability to benefit from inpatient rehabilitation have found cognitive dysfunction to be associated with a poor rehabilitation outcome. To examine whether cognitive dysfunction precluded effective rehabilitation, 52 consecutive admissions to a geriatric rehabilitation unit were assigned Mini Mental State Examination (MMSE) scores. Functional gains were assessed by the change in Functional Independence Measure (FIM) score from admission to discharge. Neither MMSE score alone nor in combination with age was significantly associated with change in FIM (r = 0.10; R = 0.25; P< 0.18). MMSE score alone and in combination with age was correlated with functional status on admission (r = 0.58; R = 0.58; P< 0.0001) and discharge (r = 0.49; R = 0.51; P< 0.0004). Patients evidenced a similar increase in functional status regardless of cognitive ability, but cognitively impaired individuals entered the inpatient unit with a lower functional status, and their level of function at discharge was also impaired relative to cognitively intact cohorts. Low MMSE scores were associated with a greater likelihood of nursing home placement, but a considerable percentage (38%) of individuals with severe cognitive impairment and the majority of individuals with mild to moderate cognitive impairment returned home following discharge. These findings suggest that geriatric patients with cognitive dysfunction should be considered for admission to rehabilitation programs if functional gains will affect quality of life or disposition.

Decision and attribution bias in neurorehabilitation.

OBJECTIVE: Examine neurorehabilitation therapists' clinical predictions and attributions for outcomes. DESIGN: Single sample, repeated measures. PARTICIPANTS: A sample of 51 neurorehabilitation therapists selected from representative disciplines including occupational therapy, physical therapy, speech therapy, and recreation therapy. MAIN OUTCOME MEASURES: Self-report questionnaire on factors related to positive and negative outcomes in neurorehabilitation. Rank order listing of factors influencing outcome in neurorehabilitation. RESULTS: Without cuing, therapists did not identify injury severity as factor in outcome (p < .0001). Therapists also made internal attributions for positive outcomes and external attributions for negative outcomes (p < .0001). CONCLUSIONS: Neurorehabilitation therapists tend to ignore injury severity as factor in outcome unless encouraged to do so. Therapists accept personal responsibility for positive outcomes, but not for negative outcomes. Neurorehabilitation teams may benefit from education on factors affecting prognosis and attribution bias found in clinical practice.

Prevalence of depression and outcome on the geriatric rehabilitation unit.

Although numerous studies have examined the prevalence of depression after stroke and its relationship to functional outcome, minimal research attention has been focused on depression in the acute inpatient rehabilitation setting. Fifty-one consecutive admissions to a geriatric rehabilitation unit were screened for depression using the Geriatric Depression Scale at both admission and discharge. Depressed v nondepressed patients were compared on the following variables: age, length of stay (days), admission Functional Independence Measure (FIM) score, discharge FIM score, change in FIM score, Mini-Mental State Exam score, and discharge to nursing home v home. Depression was prevalent in 29.4% at admission. Depression at admission was not associated with any significant differences in the above variables, but patients classified as depressed at discharge had lower FIM scores at both admission and discharge. Clinical implications and recommendations for future research are discussed.

Estimating pattern similarity for correlation matrices from differing neuropsychiatric populations.

The present example illustrates a method for assessing pattern similarity for correlation matrices from populations known to differ in clinically important respects. The data underlying previously published confirmatory factor analyses of neuropsychological traits are presented in two methods for assessing whether the matrices are similar enough to justify their aggregation into a single composite matrix. The significance of this procedure for research in applied neuropsychology is commented upon in terms of the benefits to model diagnostics.

Disability following head injury.

Disability following head injury varies depending on injury mechanism, neuropathology, and other factors, including medical complications. Mild head injury (Glasgow Coma Scale score 13-15) has been shown to have considerable variability in outcome. Some persons experience rapid symptom resolution whereas others continue to evidence symptoms for an extended duration. A small, but clinically significant number of patients may be neuropsychologically and occupationally disabled at least up to 1 year postinjury. Methodological problems continue to plague mild head injury outcome studies. In contrast, moderate (Glasgow Coma Scale score 9-12) and severe head injury (Glasgow Coma Scale score 3-8) result in more consistent patterns of disability following injury. In general, patients who sustain moderate to severe head injury tend to experience persistent and extensive neuropsychological, psychiatric, and occupational impairment. The impact of rehabilitative interventions is variable and dependent on injury severity, intervention type, and outcome criteria.

Trait analyses of the Luria-Nebraska Intellectual Processes, Motor Functions, and Memory Scales.

Trait analyses of the Luria-Nebraska's Intellectual Processes, Motor Functions, and Memory Scales were performed using multitrait-multimethod procedures and confirmatory factor analysis. Three measures each of intellectual, motor, and memory functions were administered to 161 neuropsychiatric patients. Intellectual scales (viz., Luria-Nebraska and WAIS-R) were found to have convincing discriminant properties, but motor and memory measures demonstrated visibly less such robustness. Confirmatory factor analyses supported a three-factor model of the 9 x 9 matrix, in which each of the three Luria-Nebraska scales serves as a marker for the factors. Issues related to the neuropsychological constructs, test construction, and construct validity of measurement procedures employed in clinical neuropsychology are discussed.

"Practice makes perfect:" retest effects in college athletes.

Retest effects on a diverse set of neuropsychological measures were established using a normal sample comprised of college athletes (N = 110). Results suggest that retest effects vary depending on the type of test used, but the magnitude of effect on individual tests can be quite large. Implications of using tests with large retest effects or tests without established retest effect sizes are discussed.

Confirmatory factor analytic models of the WAIS-R for neuropsychiatric patients.

Five multifactor models, in both orthogonal and oblique versions, and a single-factor model of the WAIS-R's factor pattern were examined by confirmatory maximum likelihood factor analyses of a data matrix constructed from the results for 90 neuropsychiatric patients. None of the models fits the data matrix in an absolute sense, even though all of the models represented an improvement over a null statistical model. For the multifactor models, the best results were obtained by oblique solutions, in which the degree of correlation between the factors varied from .71 to .93. The single-factor model fit nearly as well as, and in some instances better than, many of the multifactor models. The best-fitting model, viz., a three-factor oblique one, was only marginally better in its fit than two of the three two-factor models or the competing three-factor model.

The relationship between neuropsychological impairment in alcoholics and treatment outcome at one year.

One hundred and thirty-two (132) patients with a diagnosis of alcohol dependence who participated in an inpatient treatment program were assessed on select neuropsychological measures and followed for a one year period. Neuropsychological, personality, and demographic variables did not predict outcome defined as abstinence at one year follow-up. Relapsed patients displayed slightly better initial neuropsychological functioning compared to abstainers, although this effect was not significant when these measures were controlled for age and education. These findings and the clinical implications of neuropsychological assessment in alcoholic populations is discussed.

WAIS-R factor and performance on the Luria-Nebraska's Intelligence, Memory, and Motor Scales: a canonical model of relationships.

The pattern and level of performance on the WAIS-R and the Luria-Nebraska's Intelligence, Memory, and Motor Scales were examined for 93 neurologically impaired adults. Maximum likelihood factor analyses of the WAIS-R indicated the presence of strongly correlated (.72) Verbal Comprehension and Perceptual Organization dimensions. Comparisons of these factors to those of the standardization group revealed an acceptable level of similarity (.94) for Verbal Comprehension, but not for Perceptual Organization (.53). Canonical correlations between WAIS-R factor scores and the three Luria-Nebraska scaled scores accounted for 82% of the total variance. Each set of procedures evidently is indexing the same theoretical constructs. Implications of these findings for our understanding of the measurement models that underlie clinical neuropsychology are discussed.