Brain-injured Adults Research Articles

Wechsler Adult Intelligence Scale-Revised Block Design Broken Configuration Errors in Nonpenetrating Traumatic Brain Injury

Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.

Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults

Backrest positioning for brain-injured adults is variable. Some data support using a flat backrest to optimize cerebral perfusion pressure; other data support elevating the head of the bed at least 30 degrees to reduce intracranial pressure. To determine whether a flat backrest position or a backrest elevation of 30 degrees provides both optimal cerebral perfusion pressure and optimal intracranial pressure in adults with brain injuries. A randomized crossover experimental design was used to collect data on 8 adults 18 to 45 years old who had nonvascular, closed-head, traumatic brain injury. Repeated-measures multivariate analysis of variance was used to analyze the data. Overall, compared with use of a flat/horizontal position, use of a backrest elevation of 30 degrees resulted in significant and clinically important improvements in both intracranial and cerebral perfusion pressures. None of the subjects experienced adverse clinical changes in either intracranial pressure or cerebral perfusion pressure with either backrest position. The results strengthen the research foundation for raising the backrest position for adults, 18 to 45 years old, who have nonvascular, nonpenetrating, severe brain injuries.

Apolipoprotein E and Subjective Symptomatology Following Brain Injury Rehabilitation

The Apolipoprotein E (APOE) allele ε4 has been repeatedly demonstrated to be related to the development of Alzheimer's disease. We have investigated its potential significance in stroke and traumatic brain injury as reflected in outcome following neuropsychological rehabilitation of 39 brain injured adults (mean age at injury 33.3 years, range 16–56). Outcome was evaluated by rating scales derived from a questionnaire completed by each brain injured subject and by a close relative. The questionnaire scales covered physical, cognitive, emotional, and social functioning. Ten of the subjects were found to carry the APOE-epsilon4 gene and the remaining 29 did not. There were no differences between these two groups on the questionnaire scales at the time of entry into the rehabilitation programme. At follow-up, however, on average more than 1 year after completing the rehabilitation programme, scale scores for the APOE-non epsilon4 group showed significant improvements in functioning whereas the APOE-ε4 showed deterioration, the two groups differing on a global scale by 0.87 standard deviations. A battery of attention and memory tests, administered and readministered over a shorter test-retest interval, showed no such deterioration. Within the constraints of the time interval and small sample sizes involved, these findings would suggest that the presence of the APOE-epsilon4 may be associated with poorer outcome following neuropsychological rehabilitation.

Development and validation of the Validity Indicator Profile.

The Validity Indicator Profile (VIP; Frederick, 1997) is a two-alternative forced choice (2AFC) procedure intended to identify when the results of cognitive and neuropsychological testing may be invalid because of malingering or other problematic response styles. The test consists of 100 problems that assess nonverbal abstraction capacity and 78 word-definition problems. The VIP attempts to establish whether an individual's performance in an assessment battery should be considered representative of his or her true overall capacities (valid or invalid). Performances classified as valid are classified as "compliant" and reflect a high effort to respond correctly. Performances classified as invalid are subclassified as "careless" (low effort to respond correctly), "irrelevant" (low effort to respond incorrectly), or "malingering" (high effort to respond incorrectly). The VIP development sample included 944 nonclinical participants and 104 adults undergoing neuropsychological evaluation. The cross-validation sample consisted of 152 nonclinical participants, 61 brain-injured adults, 49 individuals considered to be at risk for malingering, and 100 randomly generated VIP protocols. The nonverbal subtest of the VIP demonstrated an overall classification rate of 79.8%, with 73.5% sensitivity and 85.7% specificity. The verbal subtest of the VIP demonstrated an overall classification rate of 75.5%, with 67.3% sensitivity and 83.1% specificity.

Apport de la chirurgie orthopédique pour la facilitation des soins et le confort

Purpose To define a strategy of orthopaedic surgery for severely brain-injured patients, which should allow better comfort and less nursing. To determine parameters of evaluation for this therapeutical strategy. Material and method Retrospective study of 14 totally dependant brain-injured adults (FIM < 30). Thirty-nine orthopaedic operations. Quality evaluation ease of nursing evaluated by nursing staff and family members, articular amplitudes, type and frequency of complications. Quantity evaluation: time spent on nursing. Results Medium age: 27 years (19–47). Medium FIM: 19.7 (18–20). Type of surgery: tenotomy, plastic surgery of tendons, section of capsula, excision of myositis ossificans. Decrease of complications and stable articular amplitudes through early, simple and simultaneous operations. Satisfaction of nursing staff and family; if further surgical operations were proposed, they would be accepted again. Decrease in nursing load (number of staff membres x caregiving time per 24 hours). Discussion Surgery on dependant brain-injured patients has technical (decrease of nursing, secondary prevention) and ethical (human dignity, higher quality of life) justifications. It should be part of a nursing strategy for heavily handicapped patients within their human and technical environment. Qualified evaluation tools (evaluating pain, quality of life, quantity of nursing) are needed to validate this strategy of ‘helping the helpers’.

WAIS-R Prediction Equations in Patients with Traumatic Brain Injury

Arithmetic algorithms for predicting premorbid Full Scale IQ were evaluated in a sample of 125 brain injured adults who had been evaluated within two months of their injury, and then again one year later. FSIQ at post-test was used as the criterion variable. The prediction equation, based on demographic information only (Barona, Chastain, & Reynolds, 1984), proved to be a modest predictor of premorbid FSIQ. The BEST-3 (Vanderploeg & Schinka, 1995), a prediction equation that incorporates demographic information and performance data, was sensitive to the severity of the brain injury. Subsequent analyses found the BEST-3 to be a better predictor of recovery of function than it was an estimate of premorbid functioning. This study demonstrates the need for flexibility in the interpretation of results, as what was thought to be a prediction equation for premorbid functioning was better viewed as an estimate of recovery.

Increase in extracellular glutamate caused by reduced cerebral perfusion pressure and seizures after human traumatic brain injury: a microdialysis study.

To determine the extent and duration of change in extracellular glutamate levels after human traumatic brain injury (TBI), 17 severely brain injured adults underwent implantation of a cerebral microdialysis probe and systematic sampling was conducted for 1 to 9 days postinjury. A total of 772 hourly microdialysis samples were obtained in 17 patients (median Glasgow Coma Scale score 5+/-2.5, mean age 39.4+/-20.4 years). The mean (+/-standard deviation) glutamate levels in the dialysate were evaluated for 9 days, during which the mean peak concentration reached 25.4+/-13.7 microM on postinjury Day 3. In each patient transient elevations in glutamate were seen each day. However, these elevations were most commonly seen on Day 3. In all patients there was a mean of 4.5+/-2.5 transient elevations in glutamate lasting a mean duration of 4.4+/-4.9 hours. These increases were seen in conjunction with seizure activity. However, in many seizure-free patients the increase in extracellular glutamate occurred when cerebral perfusion pressure was less than 70 mm Hg (p < 0.001). Given the potential injury-induced uncoupling of cerebral blood flow and metabolism after TBI, these increases in extracellular glutamate may reflect a degree of enhanced cellular crisis, which in severe head injury in humans appears to last up to 9 days. Extracellular neurochemical measurements of excitatory amino acids may provide a marker for secondary insults that can compound human TBI.

The PPVT-R: validity as a quick screen of intelligence in a postacute rehabilitation setting for brain-injured adults.

The utility of the Peabody Picture Vocabulary Test-Revised (PPVT-R) as a surrogate for the Wechsler Adult Intelligence Test-Revised (WAIS-R) was investigated in 61 brain-injured adult participants in a postacute rehabilitation setting. Idiographic comparison revealed substantial disagreement in clinical classification between the two instruments, and it is concluded that the PPVT-R is not a good surrogate for the WAIS-R for this purpose. In contrast, the PPVT-R was judged an adequate surrogate for the WAIS-R for the purpose of group comparison, as is common in biomedical research. Finally, contrary to prior report, the PPVT-R was demonstrated to measure more than simply Vocabulary. As such, in the absence of independent validation research, perhaps the most parsimonious conclusion regarding what the PPVT-R is measuring is that like each of the various subtests of the WAIS-R, the PPVT-R shares some of the variance of the construct termed intelligence, as well as demonstrates some unique variance that is likely comprised of error and, perhaps, a unique or different facet of intelligence.

Neurobehavioral Symptoms and Family Functioning in Traumatically Brain-Injured Adults

Traumatic brain injury (TBI) often results in a myriad of symptoms across physical, cognitive, and neurobehavioral domains. Despite inherent limitations associated with physical or cognitive impairments, the extant literature suggests that neurobehavioral symptoms tend to be the most distressing symptoms for the family and are more strongly related to poor outcome for the patient. The Neuropsychology Behavior and Affect Profile (NBAP) along with the General Functioning subscale of the Family Assessment Device (FAD-GF) and the Perceived Stress Scale were administered to 153 family members of persons who had sustained a TBI. The results provide new normative data and statistical support for the NBAP as a promising measure of neurobehavioral symptomatology following TBI. The correlation of .54 ( p < .01) between FAD-GF and Full Scale NBAP scores provides powerful support for the hypothesis that family dysfunction is related to the presence of neurobehavioral symptoms in the patient. NBAP domains of Depression, Inappropriateness, Pragnosia, and Indifference appear most strongly related to family functioning and also bear a significant relationship to caregiver stress level and patient unemployment, whereas injury severity had little impact on either family functioning or neurobehavioral symptoms. The findings reinforce the significance of neurobehavioral symptoms and fortify their proposed link to family dysfunction post-TBI.

Neurobehavioral Symptoms and Family Functioning in Traumatically Brain-Injured Adults

Traumatic brain injury (TBI) often results in a myriad of symptoms across physical, cognitive, and neurobehavioral domains. Despite inherent limitations associated with physical or cognitive impairments, the extant literature suggests that neurobehavioral symptoms tend to be the most distressing symptoms for the family and are more strongly related to poor outcome for the patient. The Neuropsychology Behavior and Affect Profile (NBAP) along with the General Functioning subscale of the Family Assessment Device (FAD-GF) and the Perceived Stress Scale were administered to 153 family members of persons who had sustained a TBI. The results provide new normative data and statistical support for the NBAP as a promising measure of neurobehavioral symptomatology following TBI. The correlation of .54 (p < .01) between FAD-GF and Full Scale NBAP scores provides powerful support for the hypothesis that family dysfunction is related to the presence of neurobehavioral symptoms in the patient. NBAP domains of Depression, Inappropriateness, Pragnosia, and Indifference appear most strongly related to family functioning and also bear a significant relationship to caregiver stress level and patient unemployment, whereas injury severity had little impact on either family functioning or neurobehavioral symptoms. The findings reinforce the significance of neurobehavioral symptoms and fortify their proposed link to family dysfunction post-TBI.

Lift/Transfer and Technical Aids for Persons with Severe Acquired Brain Injury

A questionnaire about assistive devices for lift and transfer was distributed to all individuals evaluated at the Solberga Project outpatient service unit, a regional centre for long-term follow-up of severely brain injured persons in the Greater Stockholm area. The target group was 60 severely brain injured adults, of whom 57 (30 women and 27 men) answered a questionnaire created by one of the authors. The causes of injury in the study population were trauma (n = 27), cerebrovascular accident (n = 19), anoxia (n = 10) and other (n = 1). Thirty-two persons were quadriplegic after the injury and 21 were hemiplegic. More than half (33/57) reported problems with all five defined lift and transfer situations. Most (42/44) reported problems getting in and out of their wheelchairs. Technical aids were seldom used; 24 persons did not use any aids at all. The most commonly used aid was an adjustable bed. Most of the technical aids were used when the individual also had personal assistance. The persons who managed lift and transfer by themselves used few aids. It is reasonable to assume that severely brain injured individuals would be involved in more activities if they used technical aids more readily.

Discourse after Closed Head Injury in Young Children

This study examined narrative discourse in 23 children, ages 6 to 8 years, who sustained a severe closed head injury (CHI) at least 1 year prior to assessment. Narratives were analyzed at multiple levels using language and information structure measures. Results revealed significant discourse impairments in the CHI group on all measures of information structure, whereas differences in the linguistic domain failed to reach significance. In addition, effects of age at injury and lateralization of lesion on discourse were considered. Although no significant differences were found according to age at injury, a consistent pattern of generally poorer discourse scores was found for the early injured group (<5 years). With regard to lesion focus, the group findings were unimpressive. However, preliminary examination of individual CHI cases with relatively large lateralized lesions suggested that the late injured children may show the language–brain patterns reported in brain-injured adults, whereas early injured children may not.

Impairments of discourse abilities and executive functions in traumatically brain injured adults. Brain Injury

Impairments of discourse abilities and executive functions in traumatically brain injured adults. Brain Injury

Performance of brain-injured versus healthy adults on three versions of the category test

Forty-nine healthy adults and 45 brain-injured adults were tested using one of three versions of the Category Test. Membership based on brain-injury versus non-brain-injury produced a significant main effect on the total error score for all subtests, except Subtest 2, of the Category Test. No significant differences between versions of the Category Test on total error score or an interaction between Category Test version and group membership was found. Analysis of individual subtest error scores indicated significant differences between versions on Subtest 3 and Subtest 6, with the traditional version fairing least well in differentiating brain damage. These data support the contention that the Category Test is robust to changes in the form of administration.

Reliability of a walk run test to estimate aerobic capacity in a brain-injured population

The purpose of this study was to establish the test-retest reliability of a modified 20m shuttle walk run test of aerobic capacity for adults with traumatic brain injuries TBI. A convenience sample of 18 TBI patients 16 males, two females between 19 and 58 years of age, was tested using an externally paced, progressive, maximal shuttle walk run, on two separate occasions, within a 1-week period. The test involved walking or running a 20m shuttle course while maintaining the pace determined by signals from a prerecorded audiotape. The initial slow walking pace 2 4 km h was increased gradually, each minute, until the patient could not continue. Statistical analyses revealed excellent reliability for the number of levels completed ICC 0 976, total walk run test time S ICC 0 983 and maximal heart rate attained during the final level bpm ICC 0 964. Although small but significant increases were noted for the number of levels completed during the second test, the modified 20 m shuttle walk run seems to be a reliable field test which may be useful for assessing the aerobic capacity of brain-injured adults.

Functional outcomes of older adults with traumatic brain injury: A prospective, multicenter analysis

Objective: To investigate improvement rates and medical services costs in older brain injured adults relative to younger patients. Design: Descriptive statistics were computed in a prospective comparative study of 50 patients 55 years and older and 50 patients 18 to 54 years old matched for gender and injury severity (number of days in coma, admission Glasgow Coma Score, intracranial pressure). Independent t tests were performed to examine differences between the two samples on specific variables. Setting: Five 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 531 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury between 1989 and 1994. Main Outcome Measures: Disability Rating Scale, Functional Independence Measure, Rancho Los Amigos Levels of Cognitive Functioning Scale, length of stay, acute care and rehabilitation charges, and discharge disposition. Results: Older persons averaged a significantly longer rehabilitation length of stay, higher total rehabilitation charges, and a lower rate of change on functional measures. No significant differences between groups were found for acute care length of stay, daily rehabilitation charges, acute care charges (daily or total), or discharge disposition. Conclusions: Although older persons demonstrated functional changes, the cost of change was substantially higher than for younger patients, coincident with longer lengths of stay. These higher overall charges and slower rates of change may effect changes in referral and management patterns.

Brain-injured adults' verbal memory: Implications for cognitive retraining

Brain-injured adults' verbal memory: Implications for cognitive retraining

Brain-injured adults' verbal memory: Implications for cognitive retraining

Brain-injured adults' verbal memory: Implications for cognitive retraining

Traumatic brain injury, alcohol and quantitative neuroimaging: preliminary findings.

Magnetic resonance (MR) quantitative neuroimaging analysis was undertaken with a large group of normal (n = 197) and traumatically brain injured (TBI, n = 99) adults. Of the TBI subjects 18 patients were identified with a history of substance-related abuse (TBI/Abuse group). Both the TBI/ Abuse group and the remaining sample of TBI patients (n = 81, TBI/Non-abuse group) without a history of substance-related abuse differed significantly from the control group on most quantitative MR imaging analyses. The TBI/Abuse group displayed the greatest degree of atrophic change. However, the TBI/Abuse group had a significantly lower Glasgow Coma Scale (GCS) score, ostensibly suggesting that those with substance-related abuse suffered more severe brain injury than non-abuse TBI patients. When a subset (n = 18) of the TBI/Non-abuse group was matched by GCS, gender and age to the TBI/Abuse group, both groups differed significantly from the control group on most morphometric measures, but did not differ from one another. Results are discussed in terms of the potential adverse role that substance-related abuse, particularly alcohol, plays in the individual who sustains traumatic injury to the brain.

Outcome of intensive rehabilitation after severe brain injury: a long-term follow-up study.

Fifty-five brain-injured adults (of 64 discharged) were followed up from 19 to 101 months after discharge from a rehabilitation unit. Change was assessed in terms of discharge and current placement, as compared with pre-admission placement. The results demonstrate that rehabilitation achieved improvements in functional skills and social behaviour that lastingly affected the type of placement possible, and thus improved quality of life. In most cases where improvements were seen during rehabilitation, further improvements occurred after discharge. The findings also have implications for the timing of rehabilitation and for discharge and resettlement planning.