Persistent Post-Concussive Syndrome: A proposed methodology and literature review to determine the effects, if any, of mild head and other bodily injury.

Following mild head injury, a subgroup of individuals exhibit a constellation of chronic symptoms, a condition Alexander (1995) labeled Persistent Post-Concussive Syndrome (PPCS). He implicated neurological factors in the initial phase of the syndrome but psychological factors in the maintenance of symptoms. However, it is unclear as to whether an initial mild head injury is necessary or sufficient to cause the symptoms of PPCS. We first outline a study design comparing a mild closed-head injury group to both a normal and an other injury control group to answer this question. Next, we review the literature since 1960 to determine the findings of any studies using this design. The results of the literature review indicate that few such studies exist. To date, those that have been done suggest that there is no strong evidence for a specific effect for mild head injury on cognitive functioning. We discuss directions for future research given these findings.

Depression after traumatic brain injury as a function of Glasgow Outcome Score.

One hundred and five patients with traumatic brain injury (TBI) were assessed for depressive symptomatology at 6 months postinjury and 66 of those patients were examined again at 12 months postinjury. At 6 months, 42% of the patients with TBI and 20% of the Other Injury Control Group (OIC) were identified as depressed. Individuals with poor outcome (as measured by Glasgow Outcome Score [GOS]) had a higher frequency of depressive symptomatology than those with good GOS outcome. At 12 months, 36% of the patients with TBI and 28% of the OIC group were identified as depressed. At 12 months, there was no difference in terms of frequency of depressive symptomatology among patients with TBI with poor, moderate, or good outcome.

Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury.

The present study investigated the prevalence and magnitude of depressive symptomatology in a sample of patients who had sustained traumatic brain injury (TBI) six months earlier. Depression was examined as a function of recovery outcome status, and its association with neuropsychological functioning, personal competency, and employability was also explored. Subjects were 100 patients who had previously sustained moderate-to-severe TBI who were enrolled as research subjects in the UCLA Brain Injury Research Center, and 30 matched control subjects who had sustained traumatic injuries other than to the head six months prior to evaluation. The results showed a significant association between depression and recovery status as measured by the Glasgow Outcome Scale (GOS). A significant majority of depressed subjects were found in the poorer GOS outcome groups (severe and moderate disability), compared to TBI subjects who had good GOS outcomes, and control subjects. This association was also reflected in the magnitude of the mean depression scores on two self-report measures of depression. However, no association was found between depression status and performance on the neuropsychological measures. Effects of depression were found only on an examiner-rated Patient Competency scale, and a metacognition measure based on self-report. These results are discussed in terms of brain injury severity, recovery status, and metacognition issues in TBI and other disorders.

Neuropsychological, psychosocial and vocational correlates of the Glasgow Outcome Scale at 6 months post-injury: a study of moderate to severe traumatic brain injury patients.

Traumatic brain injury (TBI) subjects at Glasgow Outcome Scale levels 3 (severe disability), 4 (moderate disability), 5 (good recovery), and an other-injury control group (OIC) were compared in terms of neuropsychological, psychosocial, and vocational functioning 6 months after injury. Subjects were a sample of 100 patients with a moderate to severe traumatic brain injury (TBI) and a matched sample of 30 other-injury control subjects (OIC) enrolled in the UCLA Brain Injury Research Center study of TBI outcome. Overall, the results showed a systematic decrease in mean neuropsychological test performance as a function of increasing GOS severity, as well as an increased prevalence of symptoms of depression and lower ratings on measures assessing employability and capacity for self care. TBI patients in the 'severe' and 'moderate disability' groups were distinctly inferior to the 'good recovery' and 'OIC' groups, who were quite similar to each other in terms of cognitive, psychosocial, and vocational outcomes. The results demonstrate overall support for the predictive and concurrent validity of the GOS 6 months post injury. Despite these results, which strengthen the utility and appeal of the GOS for multicentre studies, concerns still remain regarding GOS category 4 (moderate disability), which was shown to lack sufficient discriminability in this study.

Mild closed-head injury in children and adolescents: behavior problems and academic outcomes.

The issue of whether mild head injuries (HIs) in children cause behavior problems and poor scholastic performance is controversial. This study included 119 children (range = 8-16 years old) with HI, 114 with other injuries, and 106 with no injury (NI). Behavioral functioning was assessed with the Child Behavior Checklist; academic functioning, with school grades and standardized testing. Higher T scores were found for both injury groups versus NI participants on preinjury behavioral status. All 3 groups' behavioral scores decreased relative to baseline at 1 year. HI and NI groups did not differ in school grades or achievement testing either pre- or postinjury. These results are consistent with the conclusion that head injury of the mildest type does not increase the probability of new overt behavioral or academic problems.

Mild head injury in children and adolescents: a review of studies (1970-1995).

In this article, the authors provide a comprehensive review of the research of mild head injury in children and adolescents from 1970 to 1995. Because of marked variability in methodologies across studies, a preliminary box-score tally was computed, without regard to studies' scientific or methodological merit. These results revealed 13 adverse, 18 null, and 9 indeterminate findings related to neuropsychological, academic, or psychosocial outcome. When studies were classified based on methodological merit, the stronger studies were generally associated with null outcomes across domains. However, a few of the less stronger neuropsychological studies (5 of 40) reported subthreshold and transitory alterations during the early postinjury period. At the present time, cautious acceptance of the null hypothesis is recommended until more definitive studies are conducted that address the problems raised in this review.

Hemodynamically significant cerebral vasospasm and outcome after head injury: a prospective study.

The authors prospectively investigated cerebral hemodynamic changes in 152 patients with head injuries to clarify the relationship between cerebral vasospasm and outcome. They also sought to determine the most clinically meaningful criteria for diagnosing cerebral vasospasm. Patients with varying degrees of moderate-to-severe head injury were monitored using transcranial Doppler (TCD) ultrasonography and intravenous 133Xe-cerebral blood flow (CBF) measurements. Outcome was determined at 6 months. Using TCD ultrasonography, mean flow velocities were determined for the middle cerebral artery (V(MCA), 149 patients) and basilar artery (V(BA), 126 patients). Recordings of the mean extracranial internal carotid artery velocity (V(EC-ICA)) were also performed to determine the hemispheric ratio (V(MCA)/V(EC-ICA), 147 patients). Cerebral blood flow measurements were obtained in 91 patients. Concurrent TCD and CBF data from 85 patients were used to calculate a "spasm index" (the V(MCA) or V(BA), respectively, divided by the hemispheric or global CBF). The authors investigated the clinical significance of elevated flow velocity, hemispheric ratio, and spasm index. Patients diagnosed as having MCA or BA vasospasm on the basis of TCD-derived criteria alone had a significantly worse outcome than patients without vasospasm. When CBF was considered, hemodynamically significant vasospasm, as defined by an elevated spasm index, was even more strongly associated with poor outcome. Stepwise logistic regression analysis confirmed that hemodynamically significant vasospasm was a significant predictor of poor outcome, independent of the effects of admission Glasgow Coma Scale score and age. On the basis of the results of this study, the authors suggest that the important factor impacting on outcome is not vasospasm per se, but hemodynamically significant vasospasm with low CBF. These findings show that vasospasm is a pathophysiologically important posttraumatic secondary insult, which is best diagnosed by the combined use of TCD and CBF measurements.

Left-handedness and age: comparing writing/ drawing and other manual activities.

The percentage of individuals who use the left hand for writing/drawing, brushing teeth, and throwing a ball was compared in 3229 subjects ranging in age from 8 to 96 years. The "elimination" versus "modification" hypotheses were tested as explanations of prior observations that there are fewer left-handers among the elderly. These hypotheses predict different numbers of left-handed elderly individuals when measured by activities not influenced by social pressure. The results suggest that there are age-related patterns among different measures of left-handedness. However, a significant decline in left-handedness among the elderly was also found when measured by less culturally determined activities.

Children's color trails.

Color Trails for Children was developed in response to the need for instruments which minimize cultural bias in neuropsychological testing. The test, similar in format to Trail Making, was designed to provide an evaluation of speeded visuomotor tracking while minimizing the influence of language. The present research involves two exploratory studies which examine the relationship between Color Trails for Children and Trail Making, factors that may affect performance times, and discriminant validity. Results indicate that the tests appear to measure the same neuropsychological domains, and administration of Trail Making did not significantly alter performance times on Color Trails. Increasing age and IQ were related to quicker completion time for both tests. Females were found to complete Color Trails 2 and Trail Making Part B more quickly than males in this sample. Comparison between children diagnosed with learning disabilities, attention deficits, or mild neurological conditions and a preliminary standardization sample supported the discriminant validity of Color Traits to distinguish between normal controls and children with altered neuropsychological functioning. Comparison between clinical conditions indicated that Color Trails 2 was particularly sensitive in discriminating among the groups. Although further research is needed, results suggest that Color Trails has the potential to be an effective research and clinical tool in child neuropsychological assessment.

A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state.

It is becoming increasingly recognized that one third to one half of children diagnosed as having attention deficit/hyperactivity disorder (ADHD) continue to exhibit symptoms of the disorder into adulthood. The nature of the clinical picture is not well understood by a substantial number of clinicians. The purpose of this study is to report on the demographic and clinical profile of 56 adults, age 19 to 65 years (48 men, eight women) who present with adult ADHD and meet DSM-III-R criteria for the disorder. Patients underwent a diagnostic work-up consisting of medical and psychiatric evaluation, a structured interview Schedule for Affective Disorders and Schizophrenia-Lifetime Version [SADS-L]), the Symptoms Checklist Revised (SCL-9OR), Conners Attention Deficit Disorder With Hyperactivity (ADDH) scale, structured interview of ADDH, the Global Assessment of Functioning Scale (GAF), and, when available, information from parents was obtained. Ninety-one percent of our sample met the Utah Criteria for adult ADHD. The majority of the sample had additional DSM-III-R diagnoses and only seven had ADHD diagnosis alone. Fifty-three percent of the sample met the criteria for generalized anxiety disorder, 34% alcohol abuse or dependence, 30% drug abuse, 25% dysthymic disorder, and 25% cyclothymic disorder. These findings were similar to those reported in the literature.