Disability rating scale for severe head trauma: coma to community.

The objective of this study was to develop one instrument for assessing quantitatively the disability of severe head trauma patients so their rehabilitative progress could be followed from coma through different levels of awareness and functioning to their return to the community. This disability rating (DR) instrument was designed to be easily learned, quickly completed, valid, predictive of outcome and to have a high inter-rater reliability. The DR Scale consists of 8 items divided into 4 categories; 1. Arousal and awareness; 2. Cognitive ability to handle self-care functions; 3. Physical dependence upon others; 4. Psychosocial adaptability for work, housework, or school. Completed independently by several raters for more than 88 serious head injury patients, inter-rater correlations were highly significant. The admission DR was significantly related to clinical outcome at 1 year after injury and was significantly related to electrophysiologic measures of brain dysfunction as reflected in degree of abnormality of evoked brain potential patterns. The DR Scale is more sensitive than the Glasgow Outcome Scale in detecting and measuring clinical changes in individuals who have sustained severe head trauma. Also it can be used to help identify patients most likely to benefit from intensive rehabilitation care within a hospital setting. It provides a shorthand global description of a head injury patient's condition that facilitates understanding and communication.

Evoked potentials and head injury. 1. Rating of evoked potential abnormality.

This paper describes a method for rating the degree of abnormality of auditory, visual and somatosensory evoked potential patterns in head injury (HI) patients. Criteria for judging degree of EP abnormality are presented that allow assessment of the extent and severity of subcortical and cortical dysfunction associated with traumatic brain damage. Interrater reliability data based upon blind ratings of normal and HI patients are presented and shown to be highly significant. Tables of normative values of peak latencies and amplitudes are given and illustrations of EP patterns of different degrees of abnormality are presented.

Evoked potentials and head injury. 2. Clinical applications.

The method of rating abnormality of evoked brain potential patterns and assessing the extent and severity of cortical and subcortical brain dysfunction in head injury patients described in Part I is applied in a clinical context. Evoked potential abnormality (EPA) scores are found to be significantly correlated both with admission and outcome disability approximately one year after head injury. Correlations increase with the increase in the number of sensory modalities tested. Correlations between EPA scores and clinical disability (measured by the Disability Rating Scale) decrease with time after injury. Significant correlations, however, persist for about 60 days after onset of injury. It was found that EP pattern abnormalities can reflect specific sensory (and at times motor) deficits in noncommunicative patients and thereby contribute significantly to early treatment and rehabilitation planning.

Visual scanning and matching dysfunction in brain-damaged patients with drawing impairment.

Visual matching and visual exploration were examined in 7 normal subjects and 20 brain-damaged patients with drawing impairment measured by the Bender Gestalt Visual-Motor Test. Right brain-damaged patients made significantly more errors of rotation and integration than left brain-damaged patients. Selecteded Bender figures were also used as stimuli for both visual matching and visual exploration tests. The ability to match Bender figures was found to be impaired in right but not left brain-damaged patients. All patients showed eye movement and fixation patterns different from those normals. Patients essentially had more fixations and shorter fixation durations. Significant intercorrelations were found between the total Bender Gestalt score and visual matching and visual exploration scores. These findings indicate that visual matching and visual exploration measures can be used to evaluate perceptual impairment in individuals who do not have adequate motor responses or where impaired motor responses may confound interpretations about visual cognitive impairment.

Are there schizophrenics for whom drugs may be unnecessary or contraindicated?

This study reports that there are schizophrenics who do relatively well long term without the routine or continuous use of antipsychotic medication. Specially selected young males undergoing an acute schizophrenic episode were followed, after hospitalization, for up to three years. While hospitalized they were assigned randomly to either placebo or chlorpromazine treatment. Many unmedicated-while-in-hospital patients showed greater long-term improvement, less pathology at follow-up, fewer rehospitalizations and better overall function in the community than patients who were given chlorpromazine while in the hospital. Factors related to post-hospital outcome were good premorbid history and short-lived paranoid characteristics. Considerations which may have an effect on the successful management of acute schizophrenic patients not on medication are mentioned. The findings underline the need for further study of how to utilize antipsychotic medication more selectively in the treatment of schizophrenia.

Brain evoked potential use in a physical medicine and rehabilitation setting.

The objective of this effort was to explore the use of evoked potential (EP) procedure on a head injury unit in a Department of Physical Medicine and Rehabilitation. The method employed both auditory and visual stimulation presented bilaterally to various patients. Recordings of the brain's responses to such stimulation were obtained. Results permitted evaluation of brain stem, subcortical and cortical functioning, ipsilaterally, contralaterally, and bilaterally. EP data provided useful information for patient assessment and rehabilitation planning for head injured patients--particularly for those who were unable to cooperate in their own examination.

Evoked brain potentials and disability in brain-damaged patients.

Various measures of evoked brain potential abnormality (EPA) were correlated with disability ratings (DR) for 35 brain-damaged patients. EPA data consisted of judgements of abnormality of ipsilateral, contralateral and bilateral responses to auditory and visual stimuli reflecting activity in the brain stem, subcortex and cortex. DR data were obtained from a scale developed for this study to quantize and categorize patients with a wide range of disabilities from coma to normal functioning. EPA scores based on visual and auditory cortical responses showed significantly positive correlations with degree of disability. Visual response correlation was .49, auditory .38 and combined visual and auditory .51. It was concluded that EPA measures can reflect disability independently of clinical information. They are useful in assessing brain function in general and, specifically, in assessing impairment of sensory function. The evoked potential technique was particularly useful in patients who were not able to participate fully in their own examination. There were indications that the technique may also be valuable in monitoring progress and in predicting clinical outcome in brain-damaged patients.

Phenothiazine effects on cerebral-evoked potentials and eye movements in acute schizophrenics.

An investigation was made of the effects of phenothiazine medication on the averaged visual-evoked potentials (AVEP) and on eye movements in hospitalized, young, acute schizophrenic patients. These results were compared with those of normal subjects who were not given medication. AVEP measures included maximum amplitude (Am), frequency of peaks (FOP'S), variability (V) and peak latencies for an early negative peak (N1) and a later positive peak (P6). Eye movement measures included percent of time looking at a stimulus slide, percent of time looking at a figure on the slide, the number of fixations and the percent of cells entered in which fixations occurred. For schizophrenics off and on phenothiazine medication, there were no consistently significant drug effects on any measure except frequency of peaks. Schizophrenics compared to normals had lower amplitudes, greater frequency of peaks, greater variability and lower eye movement scores.