Outcomes from milieu-based neurorehabilitation at up to 11 years post-discharge.

Outcome in patients with brain injury after milieu-based day treatment neurorehabilitation was examined at up to 11 years post-discharge. Follow-up data in this cross-sectional study were sought from all admissions since May 1986 to May 1998 at 3 months, 1, 3, 5, 7, 9, and 11 year intervals. The 164 participants who responded had heterogeneous brain injury aetiologies and represented 73.9% of all patients who were successfully discharged from the programme. Rates of productivity (defined as gainful employment, school, and/or volunteer work) and employment (defined as work for pay) were examined in this follow-up sample. The results demonstrate that 83.5% of patients were productive up to 11 years post-discharge, with 67.1% engaged in work or school, and no decline in productivity was seen over time from discharge. Better vocational/school outcomes were associated with younger age, male gender, and higher staff working alliance ratings of patients and their families.

Milieu-based neurorehabilitation in patients with traumatic brain injury: outcome at up to 11 years postdischarge.

OBJECTIVE: To examine the rate of productivity and competitive activity in participants with traumatic brain injury (TBI) at a milieu-based day treatment neurorehabilitation program. DESIGN: Follow-up data in a cross-sectional design sought from all admissions from May 1986 to May 1998 at 3 months and at year 1, 3, 5, 7, 9, and 11. SETTING: Outpatient milieu-based interdisciplinary day treatment program. PATIENTS: One hundred twelve participants with TBI, representing 78.9% of TBI patients successfully discharged from the program. INTERVENTIONS: Milieu-based interdisciplinary neurorehabilitation (mean length of treatment, 6.2 mo). MAIN OUTCOME MEASURES: Productivity, defined as gainful employment, school, and/or volunteer work, and competitive activity, defined as work for pay or enrollment in school. RESULTS: 88.4% of patients were productive up to 11 years after discharge, with 76.8% engaged in competitive activity and with no decline in productivity seen over time from discharge. CONCLUSIONS: A large majority of patients suffering from TBI are able to return to work or a productive life situation after milieu-based neurorehabilitation. Level of outcome did not significantly decline over an 11-year follow-up interval.

Outcome assessment after milieu-oriented rehabilitation: new considerations.

OBJECTIVE: This study incorporated level of functional impairment ratings at program admission into rehabilitation outcome (return to work/school) at the time of program discharge. HYPOTHESES: (1) Patients and families with better working alliance ratings will show better adjusted outcome; (2) patients seeking compensation will have poorer outcome than those not seeking compensation or receiving benefits; (3) speed of information processing and memory will relate to the level of adjusted outcome. DESIGN: Consecutive neurorehabilitation admissions from March 1992 to May 1996. SETTING: Outpatient milieu-based interdisciplinary day treatment program. SUBJECTS: Sixty-four patients with heterogeneous brain injury etiologies. MAIN OUTCOME MEASURES: Adjusted outcome, defined as level of discharge productivity adjusted by staff ratings of functional severity of impairment at program admission; work readiness and work eagerness, based on average staff ratings. RESULTS: At discharge, 89.5% of patients showed fair or good adjusted outcome; 62% were gainfully employed/full-time students; 15.6% resumed preinjury status. Better working alliance predicted better adjusted outcome. Patients seeking compensation showed significantly lower work eagerness ratings. Poorer outcome was associated with better neuropsychological status. CONCLUSIONS: Efficacy of neurorehabilitation was demonstrated for patients with better working alliance who were not seeking compensation. Adjusted outcome demonstrated greater sensitivity and utility by incorporating the variable of functional severity of impairment at program admission. Inclusion of "process" variables addressing working alliance, motivation, and capacity to work provide important contributions to understanding rehabilitation outcome.

Suspected malingering and the Digit Memory Test: a replication and extension.

This study replicated a previous finding that suspected malingerers often perform at a level worse than patients with unequivocal brain dysfunction on the Digit Memory Test (DMT). In addition, it was demonstrated that patients suffering from aphasia as well as temporal and "frontal lobe" damage perform at a level higher than suspected malingerers. DMT performance of patients with true dementia, however, may be difficult to distinguish from suspected malingerers. If an individual is not demented (as judged by such tests as the BNI Screen for Higher Cerebral Functions) and performs at a level less than 95% across three trials of the DMT, the question of noncooperation with testing procedures or "malingering" should be considered.

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.

Methodologic issues in neuropsychological research with HIV-spectrum disease.

Conflicting data have emerged from the initial studies of the neuropsychogical sequelae of human immunodeficiency virus (HIV) infection. This paper reviews key methodologic issues that must be addressed when embarking upon new research on the neuropsychology of HIV spectrum disease. Finally, suggestions are given for methodologic pitfalls to be avoided when conducting or interpreting research in this domain.

Neuropsychologic impairment in adult bone marrow transplant candidates.

BACKGROUND: Long-term cognitive impairment has been reported in adult bone marrow transplant (BMT) recipients. However, the degree to which such impairment is attributable to the procedure or is a condition existing before BMT is not known. METHODS: The presence, nature, and correlates of neuropsychologic impairment were investigated in 55 adult BMT candidates, all of whom had a malignant condition. Impairment was assessed using a screening battery of standardized neuropsychologic tests. RESULTS: Results indicated that: (1) neuropsychologic performance was associated with specific disease and treatment risk factors, in particular a history of cranial radiation or central nervous system disease treated with intrathecal chemotherapy; (2) performance on tests reflecting memory or higher cognitive processing was more likely to be impaired; and (3) the risk of impairment increased as the number of disease and treatment risk factors for cognitive impairment in the patient increased. CONCLUSIONS: It was concluded that neuropsychologic impairment occurs in a significant minority of adult patients before BMT. Research is necessary to determine the extent to which such impairment significantly compromises patients' abilities to: (1) make decisions regarding undergoing BMT or participating in research protocols and (2) understand and execute self-care behaviors after BMT. More broadly, greater attention should be devoted to investigating the presence of long-term neuropsychologic impairment in adult patients with cancer.

Treatment of obstructive sleep apnea. A preliminary report comparing nasal CPAP to nasal oxygen in patients with mild OSA.

Nasal CPAP is presently accepted as first-line therapy for obstructive sleep apnea, but a significant minority of patients do not tolerate nasal CPAP. The purpose of this study was to compare the benefits of nasal CPAP, nasal oxygen (O2), and placebo (air) using patients as their own controls. We studied eight men, aged 33 to 72 (mean 57 years), who had mild obstructive sleep apnea. To be eligible for study, patients had to have an apnea plus hypopnea index greater than or equal to 5, plus one or more of the following: blood pressure greater than 150/95 mm Hg, multiple sleep latency test mean score less than or equal to 10 minutes, or significant nocturnal cardiac ectopy. After a baseline study, patients received a month each of nocturnal O2 at 4 LPM and air at 4 LPM, presented in random order. The third month of treatment consisted of nasal CPAP (range 2.5 to 12.5 cm H2O). Patients underwent evaluation at baseline and after each month of treatment. It was concluded that oxygen was more effective in improving oxygenation and hypopneas than is nasal CPAP. However, oxygen did not reduce apneas or improve daytime hypersomnolence as well as nasal CPAP in patients with mild OSA. Oxygen might be considered as an alternate form of treatment for patients who are not hypersomnolent, or as an adjunct to nasal CPAP.

Sleep-disordered breathing in healthy aged persons: one-year follow-up of daytime sequelae.

We studied the waking medical, sleep, and psychological status of 28 healthy older persons who had undergone nocturnal polysomnography and daytime assessment approximately 1-year earlier. In a previous report based on this sample, we found that sleep-disordered breathing (SDB) indices were not related to concurrent measurements of daytime functioning. However, in the present study, we observed relationships between the original SDB indices and several measures of cardiopulmonary functioning obtained 1 year later. At follow-up, subjects with originally high levels of SDB had significantly higher systolic blood pressure and poorer pulmonary function test results, were more likely to report irregular heartbeats in the previous year, and had experienced more disruptive snoring than the remaining subjects. When combined with other recent data, these results raise the possibility that SDB exerts an insidious pathological influence on the health and daytime functioning of otherwise healthy older persons.

Isocapnic hypoxemia and neuropsychological functioning.

We evaluated the cognitive effects of hypoxemia independent of hypocapnia in 20 right-handed male subjects using a battery of brief neuropsychological tests. Results of a profile analysis indicated that performance during hypoxia was reliably different for Digit Symbol and Finger Tapping tests. Trend analysis demonstrated a significant linear pattern for Finger Tapping results, such that lower levels of oxygen were associated with slower rates of tapping. No significant trends were observed for Digit Symbol results. The observation of hypoxic effects on Digit Symbol and Finger Tapping tests is consistent with previous findings of neuropsychological changes secondary to hypoxia. The negative results observed for the remaining tests are inconsistent with past literature. It is likely that methodological differences contributed to these discrepancies, including previous reliance on inspired air to index hypoxemia rather than monitoring arterial oxygen saturation directly and failure to control for differences in CO2 levels during induced hypoxia. These variables should be controlled in future research.