Mild traumatic brain injury does not predict acute postconcussion syndrome.

BACKGROUND: The aetiology of postconcussion syndrome (PCS) following mild traumatic brain injury (mTBI) remains controversial. Identifying acute PCS (within the first 14 days after injury) may optimise initial recovery and rehabilitation, identify those at risk and increase understanding of PCS. OBJECTIVE: To examine predictors of acute outcome by investigating the relationship between preinjury psychiatric disorder, demographic factors, injury related characteristics, neuropsychological and psychological variables and acute PCS. METHODS: Prospective study of consecutive trauma admissions to a level 1 trauma hospital. The final sample comprised 90 patients with mTBI and 85 non-brain injured trauma controls. Individuals were administered a PCS checklist, and neuropsychological and psychological measures. Multiple imputation of missing data in multivariable logistic regression and bivariate logistic regressions were used to predict acute PCS at a mean of 4.90 days after injury. RESULTS: Diagnosis of acute PCS was not specific to mTBI (mTBI 43.3%; controls 43.5%). Pain was associated with acute PCS in mTBI. The strongest effect for acute PCS was a previous affective or anxiety disorder (OR 5.76, 95% CI 2.19 to 15.0). Females were 3.33 times more likely than males to have acute PCS (95% CI 1.20 to 9.21). The effect of acute post-traumatic stress and neuropsychological function on acute PCS was relatively small. Higher IQ was associated with acute PCS. CONCLUSIONS: There is a high rate of acute PCS in both mTBI and non-brain injured trauma patients. PCS was not found to be specific to mTBI. The use of the term PCS may be misleading as it incorrectly suggests that the basis of PCS is a brain injury.

A multicentre, randomised trial examining the effect of test procedures measuring emergence from post-traumatic amnesia.

BACKGROUND: Post-traumatic amnesia (PTA) tests that record different PTA durations in the same patient, thereby raising measurement accuracy issues, have been reported previously. A major problem lies in determining the end point of PTA. AIMS: To delineate areas of discrepancy in PTA tests and to provide independent verification for a criterion signalling emergence from PTA. METHODS: In a randomised design, two related PTA procedures were compared, one purportedly more difficult (Westmead PTA Scale, WPTAS) than the other (Modified Oxford PTA Scale, MOPTAS). Eighty two patients in the early stages of PTA were examined daily until emergence, by using the Galveston Orientation and Amnesia Test (GOAT) and the WPTAS/MOPTAS. A short battery of cognitive and behavioural measurements was made on three occasions: at the early stage of PTA (time 1), towards the end of PTA when the maximum score (12/12) was first obtained (time 2) and at the traditional criterion for emergence (scoring 12/12 for 3 consecutive days; time 3). RESULTS: No significant difference was recorded in PTA duration between the MOPTAS and WPTAS. Both scales recorded longer PTA durations than the GOAT. By using Kaplan-Meier survival analyses, the WPTAS was found to show a more protracted pattern of emergence at the end stage of PTA than the MOPTAS. A time lag of > or = 1 week in the resolution of disorientation as compared with amnesia was observed in 59% cases. Significant improvements occurred on all independent measurements between time 1 and time 2, but on only 2 of 5 cognitive measurements between time 2 and time 3. CONCLUSIONS: Although no significant differences in the duration of PTA on the MOPTAS/WPTAS were recorded, emergence from the late stages of PTA occurred more promptly with the MOPTAS. The need for inclusion of both orientation and memory items in PTA tests is highlighted by the frequency of disorientation-amnesia dissociations. The patterns of results on the independent measures suggest that patients who are in PTA for > 4 weeks have probably emerged from PTA when they first score 12/12 on the MOPTAS/WPTAS, and this criterion can replace the traditional criterion.

Posttraumatic stress disorder and psychosocial functioning after severe traumatic brain injury.

The aim of this study was to investigate the influence of posttraumatic stress disorder (PTSD) on rehabilitation after severe traumatic brain injury (TBI). Ninety-six patients with severe TBI patients were assessed 6 months after hospital discharge with the Posttraumatic Stress Disorder Interview, the Functional Assessment Measure (FAM), the Community Integration Questionnaire (CIQ), the Overt Aggression Scale (OAS), the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), and the Satisfaction with Life Scale (SWL). PTSD was diagnosed in 27% of patients. Patients with PTSD reported higher scores on the GHQ and BDI, and lower scores on the FAM, CIQ, OAS, and SWLS than those without PTSD. Effective rehabilitation after severe TBI may be enhanced by management of PTSD.

Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients.

OBJECTIVE: To assess acceptability, effects on swelling, resting posture, spasticity, and active (AROM) and passive range of motion (PROM) of individually tailored upper limb Lycra garments, designed as dynamic splints to exert directional pull on certain limb segments, when worn for 3 hours by hemiplegic patients. DESIGN: Crossover trial. SETTING: Outpatient and inpatient rehabilitation center. PATIENTS: Convenience sample of 16 patients with hemiparesis and upper limb spasticity caused by a stroke more than 3 weeks before the study. INTERVENTIONS: Assessments performed at the start and end of a 3-hour period during a standard rehabilitation day when the patients were and were not wearing the garment. MAIN OUTCOME MEASURES: (1) Comfort assessed by questionnaire; (2) circumference of each limb segment; (3) resting posture at elbow and wrist; (4) spasticity at shoulder, elbow, and wrist using the Tardieu scale; and (5) AROM and PROM at shoulder, elbow, and wrist measured using a goniometer; (6) elbow proprioception using McCloskey's method; (7) visual neglect syndrome using the line bisection test. Differences between changes occurring with and without the garment were compared using Wilcoxon's signed rank test for ordinal variables (spasticity grading) and Student's t test for continuous variables (all other data). RESULTS: During 3 hours, garments worn on the arm by patients with hemiplegia (1) were comfortable, (2) improved wrist posture and reduced wrist and finger flexor spasticity, (3) reduced swelling in patients with swollen limbs (digit circumference decreased by 4%; p<.01), (4) improved PROM at shoulder (mean increase in range, 4.1 degrees +/- 13.0 degrees per shoulder movement; p<.01); and (5) impaired ability to flex fingers (range of voluntary flexion of digit III reduced from 107.3 degrees +/-79.6 degrees to 91.4 degrees +/-74.1 degrees; p<.05). CONCLUSION: Lycra garments, designed to produce continuous stretch of spastic muscles when worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia. These garments may help severely affected patients with major spasticity or painful swollen limbs.

Coping style and post-traumatic stress disorder following severe traumatic brain injury.

There is increasing evidence that a proportion of severe traumatically brain injured (TBI) patients do suffer post-traumatic stress disorder (PTSD). The aim of this study was to investigate the predictors of PTSD following severe TBI in a sample of 96 patients who sustained a severe TBI, of whom 27% satisfied diagnostic criteria for PTSD. The Post-traumatic Stress Disorder Interview, the Coping Style Questionnaire, and the Functional Assessment Measure was administered to these patients 6 months after hospital discharge. Avoidant coping style, behavioural coping style, and a history of prior unemployment were the significant predictors of PTSD severity. These findings indicate that reduction of PTSD and management of severe TBI may be facilitated by teaching patients more adaptive coping strategies.

Posttraumatic stress disorder after severe traumatic brain injury.

OBJECTIVE: This study indexed the profile of posttraumatic stress disorder (PTSD) after severe traumatic injury to the brain. METHOD: Patients who sustained a severe traumatic brain injury (N=96) were assessed for PTSD 6 months after the injury with the PTSD Interview, a structured clinical interview based on DSM-III-R criteria. RESULTS: PTSD was diagnosed in 26 (27.1%) of the patients. While only 19.2% (N=5) of the patients with PTSD reported intrusive memories of the trauma, 96.2% (N=25) reported emotional reactivity. Intrusive memories, nightmares, and emotional reactivity had very strong positive predictive values for the presence of PTSD. CONCLUSIONS: These findings indicate that PTSD can develop after severe traumatic brain injury. The predominance of emotional reactivity and the relative absence of traumatic memories in patients with PTSD who suffered impaired consciousness during trauma suggest that traumatic experiences can mediate PTSD at an implicit level.

Utility of the functional assessment measure after discharge from inpatient rehabilitation.

OBJECTIVE: To assess the relationship between the Functional Independence Measure (FIM) and the Functional Assessment Measure (FAM), and community integration and return to work in patients with severe traumatic brain injuries (TBI). DESIGN: A cross-sectional, prospective design was used to collect data at 6 and 24 months postdischarge. The Return to Work Scale (RTW) and Community Integration Questionnaire (CIQ) were selected to assess return to work and community functioning. Predictor variables included the motor and cognitive subscales of the FIM and the FAM. SETTING: Follow-up database of an inpatient and community TBI Rehabilitation Unit. PARTICIPANTS: All consenting patients with TBI admitted to the unit, aged 16 or above. There were 88 patients at 6 and 79 patients at 24 month follow-up. RESULTS: At 6 months follow-up, the FAM and the FIM were roughly equivalent in their ability to predict RTW and CIQ scores. At 24 months, FAM motor was the only significant predictor of CIQ, and FAM cognitive scores displayed an advantage over the FIM in predicting employment status. CONCLUSIONS: The FAM subscales produced only modest gains in prediction of employment status and community integration at 24 months postdischarge. This may reflect ceiling effects on the functional measures, a limited range on the RTW measure, poor ecologic validity of functional disability measures in assessing handicap, or a combination of these factors.

Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury.

OBJECTIVE: To investigate the association between posttraumatic stress disorder (PTSD) and chronic pain in patients who had sustained a severe traumatic brain injury (TBI). DESIGN: Correlational relationships between pain variables and PTSD measures were examined in a cohort study. SETTING: An adult tertiary care center brain injury clinic. PATIENTS: Ninety-six persons with severe TBI. OUTCOME MEASURES: The Posttraumatic Stress Disorder Interview (PTSD-I), a modified McGill Pain Questionnaire, the Beck Depression Inventory (BDI), the General Health Questionnaire (GHQ), the Community Integration Questionnaire (CIQ), the Satisfaction with Life Scale (SWL), and the Coping Style Questionnaire (CSQ). RESULTS: More persons with chronic pain reported PTSD than did those without pain. The relationship between pain severity and depression, functional adjustment, and satisfaction with life was mediated by severity of PTSD. Pain severity was significantly associated with an avoidant coping style. CONCLUSIONS: Effective rehabilitation of persons with chronic pain following severe TBI should recognize the role of posttraumatic stress in the maintenance of dysfunctional reactions. Specific interventions that address adaptive coping mechanisms to reduce PTSD may enhance rehabilitation for persons with TBI who suffer chronic pain.

Neuropsychological assessment and brain imaging technologies in evaluation of the sequelae of blunt head injury.

A 43 year old man with a traumatic amnesic syndrome experienced only a brief, if any, loss of consciousness following an injury to the head. Four years after this injury, his results on standard psychometric assessment were normal. Long-latency evoked response potentials results were normal, and the neurological examination and computed tomography scans were unhelpful in explaining his amnesic symptoms. He had no history of alcohol abuse, yet his neuropsychological profile was that of a Korsakoff-like amnesia with frontal lobe features. Magnetic-resonance images demonstrated evidence of extensive frontal lobe damage, while cerebral blood flow studies provided additional evidence of bilateral frontal lobe dysfunction. The case highlights the need for those giving opinions in medico-legal head trauma cases to go beyond a reliance on routine indicators, such as duration of coma, results of standard psychometric assessment and computed tomography scans, to more specialised neuropsychological evaluations and magnetic-resonance imaging scans.

Preliminary validation of a clinical scale for measuring the duration of post-traumatic amnesia.

An operational definition of post-traumatic amnesia is presented and a standardized procedure for the measurement of post-traumatic amnesia, which has been clinically tested in over 100 patients with severe, closed head injury is described. Twenty patients with severe head injuries who were still experiencing post-traumatic amnesia (as defined in this study), were assessed on an independent test of learning ability, as were 20 other patients with severe head injury who were no longer suffering post-traumatic amnesia. The performance of the two groups differed significantly; those in a state of post-traumatic amnesia performed more poorly. Both these groups showed significant impairment when compared with a control group of 20 patients who were in hospital because of orthopaedic injuries that were suffered during a motor vehicle accident. These preliminary results are sufficiently encouraging to recommend this simple procedure for routine use in hospitals, to enhance the accuracy of measuring the severity of head injury. The medicolegal use of this measure is also discussed.

Treatment of infection in the presence of an indwelling urethral catheter.

It is unnecessary to treat laboratory-diagnosed urinary tract infection in the absence of clinical symptoms and signs in patients from whom specimens of urine have been taken from indwelling urethral catheters left in situ for more than one week. If there is clinical evidence of infection, the catheter should be removed, a new catheter inserted and a specimen taken for examination. Alternatively, a suprapubic aspirate of urine may be examined bacteriologically as a treatment guide. In the absence of symptoms or other signs of infection it is doubtful whether chemotherapy is indicated.

Hyperbaric oxygen and acute spinal cord injuries in humans.

Clinical assessment of a regime of hyperbaric oxygen within 12 hours of acute spinal injury in humans suggests that further study of this method of treatment is indicated. For statistical proof of the efficacy of this form of treatment study of a large number of patients is necessary and an Australia-wide study is suggested. A recommendation is made for early referral to the spinal unit.

A new agent for the control of spasticity.

In a preliminary controlled trial, CIBA 34,647-Ba, a gamma aminobutyric acid derivative, was found to be more effective than placebo in reducing spasticity due to spinal injuries. In an uncontrolled trial, 34,647-Ba also appeared more effective than diazepam. The intensity of spasticity was measured electromyographically by the amplitude of the stretch reflex at various velocities, and the results were correlated with those obtained by clinical assessment. 34,647-Ba was effective in both complete and incomplete spinal cord lesions and it is suggested that it has an action at the spinal level. No significant side-effects were encountered.