The efficacy of traditional cultural practices in the rehabilitation of victims of torture in Nigeria's Niger Delta.

INTRODUCTION: Traditional methods of purification and healing carried out by healers and priests are of utmost importance for the mental and spiritual rehabilitation of victims of torture and perpetrators. The efficacy of traditional practices in the rehabilitation of victims of torture in Nigeria is examined. METHODS: Data is derived from 60 interviews with key informants and eight Focus Group Discussions (FGDs) conducted with victims of torture, youth militias, priests, secret cults, community leaders, women leaders, youth leaders, security agencies, and others, in local communities in the Niger Delta states of Bayelsa and Ilaje, Ondo. RESULTS: By means of reconciliation rituals, both the perpetrators and the victims are re-integrated into the community. The mental healing of victims, who were deeply traumatized by the experiences of torture during violent conflict, is an aspect of community peacebuilding that is at least as important as material reconstruction. Traditional forms of justice and reconciliation that can address the psychosocial trauma of victims of torture may be helpful in the rehabilitation process. CONCLUSIONS: This paper suggests that healing and reconciliation rituals have been an essential component of rehabilitation processes in many local communities in the Niger Delta region. International, regional and national actors and institutions must recognize the cultural importance of such rituals and their potential relevance and significance for victims of torture, but their complex dynamics need to be better understood in order to safely and effectively apply them programmatically to achieve reconciliation and rehabilitation outcomes.

Incidence and risk factors of posttraumatic seizures following traumatic brain injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: Determine incidence of posttraumatic seizure (PTS) following traumatic brain injury (TBI) among individuals with moderate-to-severe TBI requiring rehabilitation and surviving at least 5 years. METHODS: Using the prospective TBI Model Systems National Database, we calculated PTS incidence during acute hospitalization, and at years 1, 2, and 5 postinjury in a continuously followed cohort enrolled from 1989 to 2000 (n = 795). Incidence rates were stratified by risk factors, and adjusted relative risk (RR) was calculated. Late PTS associations with immediate (<24 h), early (24 h-7 day), or late seizures (>7 day) versus no seizure prior to discharge from acute hospitalization was also examined. RESULTS: PTS incidence during acute hospitalization was highest immediately (<24 h) post-TBI (8.9%). New onset PTS incidence was greatest between discharge from inpatient rehabilitation and year 1 (9.2%). Late PTS cumulative incidence from injury to year 1 was 11.9%, and reached 20.5% by year 5. Immediate/early PTS RR (2.04) was increased for those undergoing surgical evacuation procedures. Late PTS RR was significantly greater for individuals who self-identified as a race other than black/white (year 1 RR = 2.22), and for black individuals (year 5 RR = 3.02) versus white individuals. Late PTS was greater for individuals with subarachnoid hemorrhage (year 1 RR = 2.06) and individuals age 23-32 (year 5 RR = 2.43) and 33-44 (year 5 RR = 3.02). Late PTS RR years 1 and 5 was significantly higher for those undergoing surgical evacuation procedures (RR: 3.05 and 2.72, respectively). SIGNIFICANCE: In this prospective, longitudinal, observational study, PTS incidence was similar to that in studies published previously. Individuals with immediate/late seizures during acute hospitalization have increased late PTS risk. Race, intracranial pathologies, and neurosurgical procedures also influenced PTS RR. Further studies are needed to examine the impact of seizure prophylaxis in high-risk subgroups and to delineate contributors to race/age associations on long-term seizure outcomes.

Cranial injuries secondary to assault with a machete.

BACKGROUND: Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit. MATERIALS AND METHODS: Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover. RESULTS: Of 185 patients treated 172 (93%) were male. Mean age was 31±11.4 years. Mean GCS on admission was 13±2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1-145). The median GOS at discharge was 5 (range 1-5). Twelve patients died within the same admission (6.5%). CONCLUSION: Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.

Impact of late post-traumatic seizures on physical health and functioning for individuals with brain injury within the community.

PRIMARY OBJECTIVE: To better characterize, describe and highlight issues that individuals with TBI and active LPTS may face in their daily lives. DESIGN: Prospective multi-centre mixed method qualitative and quantitative interview. PARTICIPANTS: Twenty-five individuals, 5-13 years post-injury, who had reported having LPTS and TBI. MEASURES: Disability Rating Scale (DRS); Supervision Rating Scale (SRS); Glasgow Outcome Scale-Extended (GOS-E); Perceived Stress Scale (PSS); Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF) sub-scales: Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration; and Craig Hospital Inventory of Environmental Factors (CHIEF); and qualitative interview questions pertaining to management of the seizure disorder and its effect on the individual's health, function, community integration and participation. RESULTS: Data are presented regarding seizure activity and management; return to driving post-seizure; coping and participation; and standardized outcome measures. CONCLUSIONS: Individuals with TBI and LPTS are at a double-barrelled disadvantage regarding ongoing physical, cognitive, psychosocial and reintegration issues following brain injury and epilepsy. Clearer clinical guidelines and treatment strategies need to be developed to help ameliorate these ongoing issues. Additional research is needed to identify what the rehabilitation community can do to continue to facilitate people living safely and independently.

Traumatic brain injury with and without late posttraumatic seizures: what are the impacts in the post-acute phase: a NIDRR Traumatic Brain Injury Model Systems study.

OBJECTIVE: To compare and contrast the levels of impairment, disability, and community participation of individuals with traumatic brain injury (TBI) with or without late posttraumatic seizures (LPTS). DESIGN: Prospective survey study. SETTING: Community. PARTICIPANTS: Two groups of 91 individuals with TBI, with and without LPTS, were enrolled in the TBI Model Systems National Database between 1989 and 2002 and interviewed at years 1, 2, and 5 postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, injury severity, productivity, and psychosocial outcomes. RESULTS: The majority of the demographic and productivity outcomes up to 5 years postinjury were similar between individuals in the LPTS and non-LPTS groups. Both the LPTS and non-LPTS groups showed an increasing percentage of individuals who began to live alone after the first year postinjury and a decreasing percentage of individuals who were living with family members at 5 years postinjury compared with the first year post-TBI. A higher percentage of individuals in the LPTS group reported using more dependent forms of transportation such as riding with others or using public transportation. Individuals in the LPTS group had higher Disability Rating Scale scores at all time points, denoting greater functional disability, than individuals in the non-LPTS group, despite the 2 groups having similar Disability Rating Scale scores at discharge from rehabilitation. Satisfaction With Life Scale scores showed no changes over time but were significantly different between both groups at all time points, with individuals in the LPTS group reporting lower Satisfaction With Life Scale score than individuals in the non-LPTS group. CONCLUSIONS: It does appear that the development of LPTS following a TBI is associated with poorer functional and psychosocial outcomes in the first 5 years after injury. It remains to be determined whether there are other factors that also may account for these differences and that may be amenable to intervention.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities.

OBJECTIVE: This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Posttraumatic epilepsy: neuroradiologic and neuropsychological assessment of long-term outcome.

PURPOSE: We sought to detect the incidence and the risk factors of posttraumatic epilepsy (PTE) in rehabilitation patients; to define the influence of PTE for late clinical and functional outcome; and to assess the cognitive and behavioral features of the patients with PTE. METHODS: Patients were examined with (a) cognitive and behavioral examinations, which included a clinical interview and psychometric tests performed by an expert clinical psychologist; (b) single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); and (c) functional evaluation including the Glasgow Outcome Scale (GOS) and the Functional Independence Measure (FIM). RESULTS: Of the 143 patients examined in this study, in 27 (19%), seizures developed after a mean time from trauma of 11.9 +/- 8.6 months. The occurrence of PTE was significantly correlated with the hypoperfusion in temporal lobes (p < 0.004), the degree of hydrocephalus (p < 0.04), the evidence of intracerebral hematoma (p < 0.01), and operative brain injury (p < 0.001). Patients with epilepsy showed a significantly higher incidence of personality disorders than did patients without epilepsy. The uninhibited behavior, irritability, and agitated and aggressive behavior were significantly more frequent and severe in PTE patients. The psychometric tests intended to explore memory, language, intelligence, attention, and spatial cognition did not show any significant difference between those with and without epilepsy. PTE also was significantly correlated with a worse functional outcome 1 year after the trauma. CONCLUSIONS: The degrees of hydrocephalus and of hypoperfusion in the temporal lobes are significant risk factors for late PTE. Another main finding of our study is the absence of influence of epilepsy on cognitive disorders; its influence on neurobehavioral disorders and functional outcome is discussed.

Post-traumatic epilepsy in children requiring inpatient rehabilitation following head injury.

OBJECTIVE: To study the prevalence of, and identify possible risk factors for, the development of post-traumatic epilepsy in a cohort of children with severe head injury treated in an inpatient rehabilitation unit. METHODS: The hospital and community medical case notes of all children admitted prospectively to the unit and the records of the clinical EEG department over a seven year period were reviewed to identify those children who had developed late epilepsy after head injuries. RESULTS: 102 children received inpatient rehabilitation between 1 June 1991 and 28 February 1998. Follow up of these patients ranged from 18 months to over eight years. Nine patients (9%) developed post-traumatic epilepsy between eight months and over five years after the head injury. Three of the nine patients had experienced early tonic-clonic seizures in the first week after the injury. Other risk factors examined included the age of the patient, the cause of the head injury, initial Glasgow coma scale score, neuroimaging findings, and duration of ventilatory support. Only the presence of early seizures (p = 0.002) and possibly the Glasgow coma scale score (p = 0.043) were found to be specific risk factors for late late epilepsy. CONCLUSIONS: Post-traumatic epilepsy appears to be uncommon, even in children with severe head injuries. Early seizures may indicate increased risk of developing late post-traumatic epilepsy in this study population.

Post-traumatic epilepsy: its complications and impact on occupational rehabilitation--an epidemiological study from India.

The objective of this study was to assess the prevalence of seizure disorder, neuropsychiatric disorders and reproductive outcome of employees with post-traumatic epilepsy (PTE) and their effect on occupational rehabilitation. A case-comparison group study design was used to compare 30 subjects with PTE with (1) 129 non-PTE and (2) 55 non-PTE matched control employees. The 55 non-PTE matched controls were selected from the 129 non-PTE employees on the basis of age, age at onset of seizure, age at marriage and length of employment. The PTE group had a lower fertility rate than the controls and more neuropsychiatric disorders and seizure disability. PTE employees were more occupationally rehabilitated than non-PTE employees (p = 0.033). Of the 30 PTE subjects, thirteen who were rehabilitated by placement had more seizure disability (p = 0.007) and a higher fertility rate (p = 0.018). High prevalence of seizure disability and increased fertility rate among the placed PTE employees suggested that there might be some association between severity of seizures and increased production of live offspring and work placement. Work suitability or placement should not be judged on clinical assessment only but psychosocial seizure assessment, disability evaluation and other psychometric tests which are of equal importance.

The impact of posttraumatic seizures on 1-year neuropsychological and psychosocial outcome of head injury.

This study examined the relationship of posttraumatic seizures and head injury severity to neuropsychological performance and psychosocial functioning in 210 adults who were prospectively followed and assessed 1 year after moderate to severe traumatic head injury. Eighteen percent (n = 38) of the patients experienced 1 or more late seizures (i.e., seizures occurring 8 or more days posttrauma) by the time of the 1-year followup. As expected, the head injured patients who experienced late posttraumatic seizures were those with the most severe head injuries, and they were significantly more impaired on the neuropsychological and psychosocial measures compared to those who remained seizure free. However, after the effects of head injury severity were controlled, there were no significant differences in neuropsychological and psychosocial outcome at 1 year as a function of having seizures. These findings suggest that worse outcomes in patients who develop posttraumatic seizures up to 1 year posttrauma largely reflect the effects of the brain injuries that cause seizures, rather than the effect of seizures.

Use of a comprehensive programme of external cueing to enhance procedural memory in a patient with dense amnesia.

This case study describes rehabilitation efforts with a 24-year-old woman who exhibited dense amnesia secondary to status epilepticus following a motor vehicle accident. She was 20 months post-injury upon entry into our day treatment programme. The functional severity of her amnesia was reflected in numerous ways, including no recall of what she wore from day to day and an inability to find the toilet after 2 weeks in the programme. A multidisciplinary comprehensive programme of external cueing was established to exploit her preserved procedural memory. Objective measures of functional compliance were gathered over time and contrasted with both standard neuropsychological test scores and early levels of functioning in rehabilitation. Results demonstrated enhanced functioning via utilization of procedural memory. In addition, the patient actually demonstrated increased independent generalization of strategies and techniques over time. Practical treatment implications are reviewed and discussed.

Alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury.

All patients admitted to a rehabilitation unit with closed-head injury over a 3-year period were reviewed for carbamazepine use exceeding 30 days in the hospital. Nine patients met the study inclusion criteria for age and duration of carbamazepine therapy. On review of the dose:serum concentration relationship, significant changes were noted in four patients. An initial increase in the dose:serum concentration ratio during the first few months of therapy was thought to reflect the well-known auto-induction of carbamazepine metabolism. However, unexplainable decreases in the dose:serum concentration occurred in the following months, and suggested alteration of carbamazepine pharmacokinetics in patients with traumatic brain injury. The finding may be important in determining the optimal approach to therapeutic drug monitoring of carbamazepine in brain-injured patients.

Clinical management of a man with complex partial seizures and a severe head injury.

A case history of a man with complex partial seizures resulting from a severe head injury following a road traffic accident is presented. Details of medical intervention and neuropsychological assessment are also presented and discussed, highlighting the difficulties of balancing therapeutic doses of anticonvulsant medication with cognitive functioning adequate to maintain expected quality of life. An interesting finding revealed that the patient's blood-sodium levels increased rather than decreased with rising doses of anticonvulsant medication.

Rehabilitation outcomes in patients with posttraumatic epilepsy.

This study investigated 238 consecutive admissions to an adult head trauma unit during six years. Eighty-seven patients with posttraumatic epilepsy (PTE) were identified. Rehabilitation outcome was measured by a locally developed rating scale obtained at admission and discharge for all head trauma patients. The PTE and non-PTE groups were comparable in terms of demographic and medical characteristics except for proportion of men, which was higher in the PTE group (84% vs 66%, p less than .05). Both groups demonstrated significant functional gains on all measures during the course of their hospitalization (p less than .01), although the PTE patients demonstrated lower levels of function at admission and discharge on items rated by physical, occupational, speech, and recreation therapists, and by psychologists. Furthermore, PTE patients required a higher level of nursing care on discharge (p less than .05). It appears that PTE does not impede the rehabilitation process but significantly impacts posthospital rehabilitation plans of patients with blunt head injuries.

Carbamazepine replacement of phenytoin, phenobarbital and primidone in a rehabilitation setting: effects on seizure control.

Most patients who receive anticonvulsants after traumatic brain injury are treated with the sedative anticonvulsants phenytoin and/or phenobarbital, or perhaps primidone. However, there is considerable evidence demonstrating that these medications have a deleterious effect on cognitive function. Thus, in a rehabilitation setting, alternatives should be sought. Carbamazepine has been found to be relatively free of such effects, and would be an optimum alternative if seizure control were comparable. We have studied the effects of withdrawing phenytoin, phenobarbital and primidone, and using carbamazepine as the primary anticonvulsant in 27 patients at the Greenery Rehabilitation and Skilled Nursing Center for whom ongoing anticonvulsant treatment was considered to be necessary due to previous seizures or a high risk of the occurrence of seizure. We compared a 3 month baseline period (just prior to carbamazepine introduction or sedative anticonvulsant tapering), to a 3 month post-withdrawal period immediately following sedative anticonvulsant withdrawal, when carbamazepine was the sole anticonvulsant. In 20 out of 21 patients in whom carbamazepine replaced sedative anticonvulsants seizure control was essentially similar or somewhat improved. In only one patient did the substitution with carbamazepine result in a loss of seizure control. Six patients were initially receiving carbamazepine in combination with phenytoin and/or phenobarbital. The removal of phenytoin and phenobarbital, leaving carbamazepine as sole therapy, resulted in improved seizure control in three patients and no change in the other three. In the light of carbamazepine's reportedly less detrimental effects on cognitive function and behaviour in other patient populations, it should perhaps be considered as a first line anticonvulsant, especially for patients in rehabilitation settings.

[Value of psychophysiological studies in the evaluation of the rehabilitation of patients with sequelae of brain injuries]. / Znachenie psikhofiziologicheskikh issledovanii v otsenke reabilitatsii bol'nykh s posledstviiami travm golovnogo mozga.

A clinical, follow-up and psychophysiological (including investigations of the auditory, visual and motor analyzers) study involved 123 patients with psychic sequelae of brain injuries (51 patients with posttraumatic psychopathy-like syndrome and 72 patients with traumatic epilepsy). Criteria of clinical and sociooccupational compensation of patients have been developed. The results have been processed by analysis of correlations and multifactorial analysis of variances. The authors have developed a score scale for the evaluation of analyzer functions to objectively assess the severity of long-term sequelae of head traumas and of the effectiveness of therapeutic rehabilitative and readaptational impacts. The authors have demonstrated the possibility of using some psychophysiological parameters as additional characteristics of rehabilitative potentials of patients suffering from brain trauma aftereffects.

[Rehabilitation of patients with traumatic epilepsy]. / Reabilitatsiia bol'nykh travmaticheskoi épilepsiei.

The results of multimodality rehabilitation treatment of 85 patients with traumatic epilepsy are presented. Complete social compensation or less pronounced compensation was achieved in 61 patients with regressive and slowly progressive course of the disease. Complete disadaptation occurred in 12 patients with the progressive type of the disease. The multimodality treatment with the use of anticonvulsants should include drugs of metabolic action (nootropic agents), neuroleptics and tranquilizers.

[Rehabilitation of patients with defects of the bones of the skull after craniocerebral injury]. / Reabilitatsiia bol'nykh s defektami kostei cherepa posle cherepno-mozgovoi travmy.

Patients with defects of the cranial bones were followed up for from one to ten years and over by employing clinical, electrophysiological, psychological, and social research methods. Combined assessment of cerebral dysfunctions showed the presence of general cerebral symptomatology which, in the period of decompensation, manifested itself in hypertensive and hypothalamic crises, as well as in psychopathological disturbances. The latter were controlled by courses of rehabilitation treatment. In the period between the crises, the patients with a substituted defect of the cranial bones were capable of many kinds of working activities, which suggests that the acknowledgement of an "anatomical defect" in which event the degree of disability is established once and for all is warranted only in cases of unsubstituted defects of the cranial bones (3 X 1 cm, according to the Manual of identifying the degree of disability, 1956).