Traumatic brain injury/chronic pain syndrome: a case comparison study.

OBJECTIVE: To identify the pretreatment characteristics and progress in treatment and outcomes of chronic pain patients, with and without concomitant traumatic brain injury (TBI). DESIGN AND PATIENTS: Retrospective cohort study of 12 consecutive patients in a chronic pain treatment program who were discovered to have previously untreated brain injury and a cohort of 12 chronic pain patients from the same program matched for age and sex who did not have brain injury. SETTING: Interdisciplinary university-based outpatient rehabilitation medicine clinic. MAIN OUTCOME MEASURES: Length of time in treatment and vocational outcomes. RESULTS: A surprising number of patients referred for treatment of chronic pain were found to have history and symptoms indicative of previously untreated or undiagnosed mild traumatic brain injury (n = 21 of 65). Of these, 12 received therapy for both their brain injury and chronic pain. The 12 treated, dual diagnosed patients did not differ in terms of education, employment status, or marital status from the chronic pain patients. Those with TBI were more likely to have sustained an automobile injury and less likely to have a work-related injury. On admission, 25% of each group were working, and at discharge, that proportion reached 75% for each group. Those with TBI required significantly longer treatment (459 consecutive days) from intake to discharge compared with the control group (295 days). CONCLUSION: Patients who exhibit memory or concentration problems, who express confusion about their diagnosis, who were injured in an automobile accident, or who complain of pain in the head, neck, or arms should be questioned about the possibility of concurrent TBI. Most of these patients can achieve successful employment outcomes, however, the TBI group may require a longer treatment time.

Employment following severe traumatic brain injury: the utility of the Individual Ability Profile system (IAP).

The results of a survey of employment outcome and their relationship to psychometric indices indicated that competitive employment following severe traumatic brain injury is an ambitious endeavor. While 98% of the subjects sampled were either employed or in school premorbidly, 43% of the subjects were unemployed postinjury. Specifically, the Individual Ability Profile (IAP) ([Dean, 1982][Dean, 1983]) variables developed to assist in the clinical interpretation of the results of the WAIS-R were most highly related to employment outcome. A discriminant function analysis utilizing these variables yielded hit rates of 82% for the unemployed category and 92% for the full-time employment grouping. These results further highlighted the useful role of neuropsychological testing in assisting in vocational rehabilitation planning. Future research is required to further elucidate those neuropsychological abilities that subsequently affect employability following severe traumatic brain injury.

Marital status and adjustment to spinal cord injury.

Individuals with spinal cord injury were studied in 1974 (N = 256), 1985 (N = 347) and 1989 (N = 286) using the Life Situation Questionnaire (LSQ). The latter surveys included nearly all of the surviving participants from the 1974 sample plus a new sample of individuals with more recent injuries. Items covered activities, frequency of medical treatment, ratings of satisfaction with various aspects of life, ratings of problem areas, and judgments regarding personal adjustment to SCI. Subjects were grouped according to marital status (single, married or other) and compared on these variables. The single group was somewhat younger than the other two and included a higher proportion of employed individuals. Few differences were found in terms of subjective adjustment variables, however, possibly because the married group included both individuals who were married before their injuries and those married afterwards. A second set of analyses reported in this paper focused on subjects who were single during the 1974 study. On data collected in 1974 as well as data from 1985, the group who married were measurably different in several respects from those who remained single. This suggests that individuals in post-injury marriages were a select group and that the experience of marriage further strengthened their satisfaction with life and with their own adjustment.

Ageing and severe physical disability: patterns of change and implications for services.

For the first time in history, numbers of people with severe physical disabilities such as spinal cord injury or polio are surviving to old age. Ageing-related changes combined with pre-existing impairments present new challenges for these individuals and for service providers. Implications for professionals include the need to foster more collaborative relationships between themselves and recipients, to emphasize services that enable independence, to coordinate new services, and to address issues of wellness, not only disability.

Chronologic age, time since injury, and time of measurement: effect on adjustment after spinal cord injury.

People are now living longer after spinal cord injury (SCI), yet only limited research has addressed the issue of aging and adjustment after SCI. The purpose of this study was to use a time-sequential design to identify the relationship between adjustment after SCI and three facets of aging; chronologic age, time since injury, and time of measurement. Life Situation Questionnaires were obtained from one sample of participants with SCI in 1974 (n = 256) and from a second sample in 1985 (n = 193). Participants were grouped into five cohorts based on chronologic age, five cohorts based on time since injury, and two groups based on time of measurement (1974, 1985). Two two-way MANOVA's were performed, one between chronologic age and time of measurement, and the other between time since injury and time of measurement. Results indicated that chronologic age and time since injury often worked in opposing directions; as some aspects of adjustment declined with greater chronologic age, but other aspects improved with increasing time since injury. Activity was strongly related to chronologic age, but medical stability was more strongly related to time since injury. Both chronologic age and time since injury were correlated with some aspects of life satisfaction. Comparisons between the two times of measurement (1974, 1985) indicated some limited positive changes in adjustment with time. The results point to the complexity of the relationship between aging and adjustment and the need for rehabilitation professionals to consider multiple aging factors.

Marital relationships and spinal cord injury.

A questionnaire study of 122 married individuals with spinal cord injury (SCI) revealed a number of differences between the marriages that took place after the onset of disability and those that had occurred earlier. The two groups were equivalent in terms of severity and duration of disability, but those married before SCI were older. ANCOVA was used in most analyses to control for age at the time of injury and at present. Those married after injury reported greater satisfaction with their sex lives, living arrangements, social lives, health, emotional adjustment, and control over their lives, and they indicated that loneliness was less of a problem. They were also far more likely to be working and to be socially active outside their homes.

Functional assessment in vocational rehabilitation: a systematic approach to diagnosis and goal setting.

The Functional Assessment Inventory (FAI) has been developed for diagnostic use in vocational rehabilitation. This study involved field testing and initial validation of the Inventory as a diagnostic tool. Thirty vocational rehabilitation counselors administered the Inventory to 351 clients. Factor analysis identified 8 scales: Cognitive Function, Motor Function, Personality and Behavior. Vocational Qualifications, Medical Condition, Vision, Hearing, and Economic Disincentives. Content and concurrent validity of the Inventory were assessed by comparing the scores of clients grounded by medical diagnosis and by relating scores to counselors' judgments of severity of disability and employability. Clients with various primary disabilities appeared to differ from one another on the factor scales and on individual items in predictable ways. Total Functional Limitations scores were highly correlated with counselors' ratings of severity of disability and employability.

Spinal cord injury: a comparison of preinjury and postinjury marriages.

A study of the preinjury and postinjury marriages of 55 spinal cord injured persons and their partners revealed several differences between the relationships. Although all patients had comparable levels of spinal cord injury, the disabled persons in preinjury marriages were judged to have less motivation for independence; a larger proportion of them received daily personal care assistance from their spouses. Furthermore, those in postinjury marriages were more likely to be employed and were judged to be better adjusted psychologically. Psychologists' assessment of marriages based on interviews with the spinal cord injured subjects and their spouses revealed that the postinjury marriages were happier than the preinjury marriages. Possible explanations for these findings are discussed, which include age and state of health, the impact of disability on the marital relationship and the personal assets of disabled persons who attract new partners.

Stroke rehabilitation: evaluation of its quality by assessing patient outcomes.

A modified version of an outcome-oriented quality-assurance system was used to assess the care received by patients, aged 21 to 60 years, with completed stroke, who had participated for at least three weeks in a rehabilitation program. Care for 110 patients was evaluated by comparing actual results with a set of standards for outcomes produced by practicing rehabilitation professionals using small-group estimation techniques. Outcomes were better than estimated, standards having indicated that 29% of patients should be capable of self-care, while actually 43% were. When 50 of the 110 outcomes were individually investigated; only 5% of the total study population were probably not functioning at an optimal level, and 3% more might reach optimal functioning if existing follow-up procedures were extended and made more routine. Since only an estimated 3 to 6 cases per year would be affected, the cost of instituting such care would not be justified. Participants concluded that assessment of outcomes justified continuation on the existing processes for stroke rehabilitation.

Vocational diagnosis through assessment of functional limitations.

Diagnosis in rehabilitation counseling requires a relatively precise delineation of client assets and liabilities. This is essential in establishing direction for counseling efforts; it can also aid in evaluating counseling effectiveness by providing a means of grouping cases according to difficulty or types of problems. This paper identifies the disadvantages of present systems of medical and psychiatric diagnoses for these vocational counseling purposes. It discusses some of the methodological issues involved in establishing a new system for recording client problems. The paper also introduces a brief, yet comprehensive inventory of functional limitations which has been developed in the Counseling Psychology Service of the Department of Physical Medicine and Rehabilitation at the University of Minnesota.