Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury.

PRIMARY OBJECTIVES: To measure common psychiatric conditions after military deployment with blast exposure and test relationships to post-concussion syndrome (PCS) symptoms and mild traumatic brain injury (mTBI) history. RESEARCH DESIGN: Cross-sectional. METHODS AND PROCEDURES: Service members or Veterans (n = 107) within 2 years of blast exposure underwent structured interviews for mTBI, post-traumatic stress disorder (PTSD) and multiple mood and anxiety diagnoses. MAIN OUTCOMES AND RESULTS: MTBI history and active PTSD were both common, additionally 61% had at least one post-deployment mood or anxiety disorder episode. Psychiatric diagnoses had a high degree of comorbidity. Most dramatically, depression was 43-times (95% CI = 11-165) more likely if an individual had PTSD. PCS symptoms were greater in those with post-deployment PTSD or mood diagnosis. However, neither mTBI nor blast exposure history had an effect on the odds of having PTSD, mood or anxiety condition. CONCLUSIONS: These findings support that psychiatric conditions beyond PTSD are common after military combat deployment with blast exposure. They also highlight the non-specificity of post-concussion type symptoms. While some researchers have implicated mTBI history as a contributor to post-deployment mental health conditions, no clear association was found. This may partly be due to the more rigorous method of retrospective mTBI diagnosis determination.

EFFECT OF JOB SKILLS TRAINING ON EMPLOYMENT AND JOB SEEKING BEHAVIORS IN AN AMERICAN INDIAN SUBSTANCE ABUSE TREATMENT SAMPLE.

Employment difficulties are common among American Indian individuals in substance abuse treatment. To address this problem, the Southwest Node of NIDA's Clinical Trials Network conducted a single-site adaptation of its national Job Seekers Workshop study in an American Indian treatment program, Na'Nizhoozhi Center (NCI). 102 (80% men, 100% American Indian) participants who were in residential treatment and currently unemployed were randomized to (1) a three session, manualized program (Job seekers workshop: JSW) or (2) a 40-minute Job Interviewing Video: JIV). Outcomes were assessed at 3-month follow up: 1) number of days to a new taxed job or enrollment in a job-training program, and 2) total hours working or enrolled in a job-training program. No significant differences were found between the two groups for time to a new taxed job or enrollment in a job-training program. There were no significant differences between groups in substance use frequency at 3-month follow-up. These results do not support the use of the costly and time-consuming JSW intervention in this population and setting. Despite of the lack of a demonstrable treatment effect, this study established the feasibility of including a rural American Indian site in a rigorous CTN trial through a community-based participatory research approach.

Alterations of medial preoptic area neurons following pregnancy and pregnancy-like steroidal treatment in the rat.

There is a marked increase in the maternal behavior displayed by a female rat following pregnancy-due primarily to exposure to the gonadal hormones progesterone and estradiol (P and E(2), respectively). We examined Golgi-Cox silver-stained, Vibratome-sectioned neurons visualized and traced using computerized microscopy and image analysis. In Part One, we examined the hormonal-neural concomitants in the medial preoptic area (mPOA), an area of the brain that regulates maternal behavior, by comparing cell body size (area in microm(2); also referred to as soma and perikaryon) in the mPOA and cortex of five groups (n = 4-6/group) of ovariectomized (OVX-minus), diestrous, sequential P and E(2)-treated (P+E(2)), late-pregnant, and lactating rats; for Part Two, we examined a subset of mPOA neurons, which were traced in their entirety, from these same subjects. In Part One, whereas there was no difference between OVX-minus and diestrous females, both had smaller somal areas compared to OVX+P+E(2)-treated and late-pregnant females. The area of the soma returned to diestrous/OVX-minus levels in the lactating females. We found no change among the five groups in area of cell body in cortical neurons, which generally lack steroid receptors. In Part Two, which included a more detailed morphometric analysis of mPOA neurons, we examined several additional measures of dendritic structure, including number of proximal dendritic branches (the largest proximal dendrite was defined as the one with the largest diameter leaving the soma); cumulative length of the largest proximal dendrite; area of the cell body; number of basal dendrites; cumulative basal dendritic length; number of basal dendritic branches; and branch-point (distance from cell body to first branch of largest proximal dendrite). Again, we found similar effects on cell body size as in Part One, together with effects on number of basal dendritic branches and cumulative basal dendritic length in pregnant and P+E(2)-treated groups compared to OVX, diestrous, and lactating. An increase in somal area denotes increased cellular activity, and stimulatory effects on additional neuronal variables represents modifications in information processing capacity. Pregnancy and its attendant hormonal exposure, therefore, may stimulate neurons in the mPOA, which then contribute (in an as yet undetermined manner) to the display of maternal behavior. During the postpartum lactational period, when cues from pups primarily maintain maternal attention, the neuronal soma appears to return to a pre-pregnancy, non-hormonally dependent state, whereas other aspects of the dendrite remain altered. Collectively, these data demonstrate a striking plasticity in the brains of females that may be reflected in modifications in behavior.

Relation of electromyography-induced pain to type of recording electrodes.

Pain is an important consideration in the performance of needle electromyography (EMG). Prior investigations have suggested that pain is greater with a concentric needle electrode (CNE) than monopolar needle electrode (MNE). This prospective randomized study tested this hypothesis using improved methodology and disposable rather than reusable needle electrodes. Ninety consecutive outpatients were enrolled and randomized to CNE (diameter = 0.46 mm) or MNE (diameter = 0.41 mm) arms. Subjects underwent a standardized 4 limb-muscle needle EMG protocol during which pretest and posttest verbal analog pain scale (0-10) measures were obtained. As anticipated, EMG-induced pain was significantly higher (P < 0.001) than pre-EMG baseline pain. However, analysis of variance (ANOVA) revealed no significant differences in pain ratings between the CNE and MNE arms. Among other factors analyzed, only gender significantly influenced EMG-induced pain, with females reporting higher levels than males. Thus, pain is not an important selection criterion for type of disposable needle electrode.

Inpatient interdisciplinary rehabilitation after total hip arthroplasty surgery: a comparison of revision and primary total hip arthroplasty.

OBJECTIVES: To describe outcomes of revision total hip arthroplasty (THA) patients who underwent interdisciplinary inpatient rehabilitation, and to compare them with primary THA patients. DESIGN: Descriptive and case-control study. SETTING: Forty-bed, community-based, freestanding rehabilitation hospital. PATIENTS: Thirty-nine revision THA subjects, gender- and age-matched with 39 primary THA controls. INTERVENTION: Inpatient interdisciplinary rehabilitation. MAIN OUTCOME MEASURES: FIM instrument, length of stay, hospital charges, and disposition location. RESULTS: The average revision THA patient stayed 10.5 days, improved from an admission FIM score of 89 to a discharge FIM score of 110, and incurred a hospital charge of $10,600. Of the revision THA patients, 98% were discharged home, and orthopedic-related complications were uncommon. No significant differences existed between revision and primary THA patients in any outcome measures. A trend toward higher rehabilitation charges ($12,400 vs $9500, p =.07) was found in revision THA patients who wore a hip orthosis. Otherwise, no differences were found in outcome measures based on the type of revision surgery, the presence of weight-bearing restrictions, or the presence of orthopedic complications. CONCLUSIONS: THA patients selected for inpatient rehabilitation have favorable short-term functional outcomes. The type of THA (primary vs revision) is not an independent differentiating factor.

Functional assessment in patients with chronic pain: can physicians predict performance?

OBJECTIVES: To determine the appropriateness of using physicians to estimate the functional abilities of patients with chronic pain. Specific objectives included the following: (1) to compare the physician's predicted performance on functional assessment with actual performance, and (2) to compare the physician's predicted effort during functional assessment with an objective measure of effort. DESIGN: A total of 201 outpatients with chronic pain completed this prospective, multicenter, cohort study. Fifteen physicians, who were trained to administer the standardized evaluation, performed the evaluations and predicted performance and effort on functional assessment. Therapists, blinded to the physician's evaluation, administered a functional assessment (maximal and sustained lifts [n = 3 types]; repetitive activities [n = 4 types]) and a grip dynamometry test (effort measure) on each subject. RESULTS: Pearson's correlation testing demonstrated significant correlations between the physician's predicted performance and the observed performance for all lifting items and repetitive activities in both men (0.52, 0.50, 0.55) and women (0.36, 0.40, 0.18). Analysis of variance and post hoc t tests showed agreement between the physician's predicted effort and the dynamometry effort measure in only a small subset of patients (men were predicted to put forth absolutely no effort; n = 4). CONCLUSIONS: A trained physician, performing a standardized evaluation, can estimate with reasonable accuracy the work-related functional ability in patients with chronic pain. The prediction of effort seems to be more problematic.

Functional outcomes in patients with brain tumor after inpatient rehabilitation: comparison with traumatic brain injury.

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of individuals with brain tumor versus those with acute traumatic brain injury. DESIGN: In this study, 78 brain tumor patients were one-to-one matched by location of lesion and age with 78 acute traumatic brain injury patients. Outcome was measured by using the Functional Independence Measure (FIM 228) on admission and discharge. The FIM change and FIM efficiency were also calculated. FIM data were analyzed in three subsets, i.e., activities of daily living, mobility, and cognition. Discharge disposition and rehabilitation length of stay were also compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and the traumatic brain injury populations with respect to total admission FIM, total discharge FIM, and FIM efficiency. The brain injury population had a significantly greater change in FIM. The tumor group had a significantly shorter rehabilitation length of stay and a greater discharge to community rate. CONCLUSIONS: Thus, individuals with brain tumor can achieve comparable functional outcome and have a shorter rehabilitation length of stay and greater discharge to community rate than individuals with brain injury.

Impact of clinically significant heterotopic ossification on functional outcome after traumatic brain injury.

OBJECTIVE: To assess heterotopic ossification's (HO) impact on functional outcome after TBI. DESIGN: Retrospective with matched control group, single center. SETTING: TBI Model System of Care at the Medical College of Virginia of Virginia Commonwealth University, Richmond, VA. PARTICIPANTS: Twenty-six patients with TBI and triple-phase bone scan confirmed HO were matched with 26 patients without clinical evidence of HO. MAIN OUTCOME MEASURES: Acute and rehabilitation lengths of stay (LOS), Admission and Discharge Functional Independence Measure (FIM) scores, FIM change, FIM efficiency (FIM gains per week), and discharge disposition. RESULTS: The two groups had similar acute care LOS. Patients with HO had significantly longer inpatient rehabilitation LOS and significantly lower FIM mobility and activities of daily living subscale scores on admission and discharge. FIM efficiency was significantly lower for the group with HO. Significantly fewer patients with HO were able to be discharged to home. CONCLUSIONS: HO is associated with a poorer functional outcome; however, it is not clear whether HO causes the decreased function or whether it may serve more generally as an indicator of those patients who will not progress as far or as rapidly during inpatient rehabilitation.

Functional outcome of individuals with traumatic brain injury and lower extremity deep venous thrombosis.

OBJECTIVE: To determine the impact of acute lower extremity (LE) deep venous thrombosis (DVT) on functional outcome after traumatic brain injury (TBI). SETTING: Tertiary university medical center rehabilitation unit. SUBJECTS: Ninety-two TBI rehabilitation patients (46 patients with DVT and 46 patients without DVT). Forty-six TBI patients with a diagnosis of LE DVT were 1:1 matched with non-DVT TBI patients. Matching criteria included: primary diagnosis of TBI, admission Functional Independence Measure (FIM), Glasgow Coma Scale (GCS), and age. OUTCOME MEASURES: FIM (admission, discharge, change, and efficiency), FIM subscores (activities of daily living [ADL], mobility, cognition), length of stay ([LOS] acute and rehabilitation), and discharge living disposition. DESIGN: Cohort study utilizing prospectively collected data. DVT diagnoses were made upon rehabilitation admission using color flow duplex Doppler ultrasonography. Descriptive statistics were run on demographic variables. Analyses of variance (ANOVAs) were performed on the sample with regard to outcome measures, including FIM scores, FIM subscores, and LOS (acute and rehabilitation). RESULTS: No significant between-group differences were found concerning LOS, rehabilitation costs, FIM total, or FIM subgroup scores. Chi-squared analyses revealed significant differences between groups with regard to discharge living disposition (chi(2) = 4.7, P <.03). CONCLUSION: Lower extremity DVT does not appear to interfere with functional outcome after TBI. The data suggest that this patient population is appropriate for admission or continued participation in acute inpatient rehabilitation, despite the presence of LE DVT.

Functional outcome after brain tumor and acute stroke: a comparative analysis.

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN: Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS: Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES: The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION: Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.

Rehabilitation outcome of individuals with nontraumatic myelopathy resulting from spinal stenosis.

A study was undertaken of 46 patients (19 cervical and 27 lumbar) admitted to an inpatient rehabilitation unit following surgical decompression for myelopathy or cauda equina syndrome resulting from spinal stenosis (SS). Individuals with SS represented 16 percent of all spinal cord injury (SCI) admissions. When compared to patients with traumatic SCI, patients with SS were significantly (t-test, p < .01) older (mean age 68 versus 39 years), more frequently retired/unemployed (89 percent versus 43 percent), more often married (57 percent versus 36 percent) and less often male (54 percent versus 82 percent) but with similar ethnicity. Significant (p < .01) Functional Independence Measurement (FIM) changes for the SS patients were noted after rehabilitation in the categories of self-care, sphincter control and mobility/locomotion. Additionally, outcome comparisons with a group of traumatic SCI patients who had similar motor function revealed similar lengths of stay, discharge FIM scores and discharge-to-community rates. This study suggests that individuals with weakness secondary to SS represent a significant proportion of individuals with SCI, make significant functional gains following inpatient rehabilitation and can achieve functional outcomes similar to those of traumatic SCI individuals.

Comparison of rehabilitation outcomes in violent versus non-violent traumatic SCI.

This paper represents the results of a cohort study comparing functional outcomes of individuals with violent and non-violent traumatic spinal cord injury (SCI) following inpatient rehabilitation. Twenty-seven consecutive patients with a diagnosis of traumatic SCI of violent etiology (gunshot wound, stabbing or assault) and 27 patients with non-violent etiology (motor vehicle accident and falls) were matched for neurological level of injury and classification. Demographic comparison of violent versus non-violent groups revealed mean age 30 versus 39, gender 93 percent versus 78 percent male, race 89 percent versus 59 percent non-white, 74 percent versus 41 percent unmarried and 56 percent versus 22 percent unemployed, respectively. Violent and non-violent traumatic SCI groups had similar lengths of stay, admission and discharge functional independent measures (FIM), FIM improvement, payor sources, hospital charges and discharge to home rates. Despite the differences noted in the demographics of violent and non-violent traumatic SCI, these two matched groups achieved similar functional outcomes and discharge disposition following inpatient rehabilitation.

The association between gender, race and marital status on functional outcome at rehabilitation discharge after thromboembolic stroke: a prospective analysis.

Appropriate allocation of rehabilitation resources requires that the rehabilitation professional have a knowledge of reliable predictors of functional outcome. To determine what influence pre-morbid demographic variables have on functional outcome following thromboembolic stroke, we analyzed prospectively collected demographic and functional data from consecutive patients admitted to rehabilitation at a tertiary university medical center. Data from 117 patients were statistically analyzed for correlations between demographic factors and functional outcome as measured by the FIM scale and hospital length of stay (LOS). While no significant correlations were found between race or gender and functional outcome, Caucasians were found to stay an average of 5 days longer in acute care than African-Americans. Non-married patients were found to have significantly longer rehabilitation LOS and return home following discharge less often. It is concluded that non-married status is a significant negative prognostic factor for functional outcome after thromboembolic stroke, while gender and race have no correlation.

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients. DESIGN: Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up. MAIN OUTCOME MEASURE: Return to work at 1-year follow-up. RESULTS: Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts. CONCLUSIONS: Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patient's ability to return to work, as well as an operational definition for successful employment.