Duration Of Post-traumatic Amnesia Research Articles

Strategies to avoid a missed diagnosis of co-occurring concussion in post-acute patients having a spinal cord injury.

Research scientists and clinicians should be aware that missed diagnoses of mild-moderate traumatic brain injuries in post-acute patients having spinal cord injuries may approach 60–74% with certain risk factors, potentially causing clinical consequences for patients, and confounding the results of clinical research studies. Factors leading to a missed diagnosis may include acute trauma-related life-threatening issues, sedation/intubation, subtle neuropathology on neuroimaging, failure to collect Glasgow Coma Scale scores or duration of posttraumatic amnesia, or lack of validity of this information, and overlap in neuro-cognitive symptoms with emotional responses to spinal cord injuries. Strategies for avoiding a missed diagnosis of mild-moderate traumatic brain injuries in patients having a spinal cord injuries are highlighted in this perspective.

Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury.

Survivors of moderate-severe Traumatic Brain Injury (TBI) are at risk for long-term cognitive, emotional, and behavioural problems. This prospective cohort study investigated self-reported executive, emotional, and behavioural problems in the late chronic phase of moderate and severe TBI, if demographic characteristics (i.e., age, years of education), injury characteristics (Glasgow Coma Scale score, MRI findings such as traumatic axonal injury (TAI), or duration of posttraumatic amnesia), symptoms of depression, or neuropsychological variables in the first year after injury predicted long-term self-reported function. Self-reported executive, emotional, and behavioural functioning were assessed among individuals with moderate and severe TBI (N = 67, age range 15–65 years at time of injury) 2–5 years after TBI, compared to a healthy matched control group (N = 72). Results revealed significantly more attentional, emotional regulation, and psychological difficulties in the TBI group than controls. Demographic and early clinical variables were associated with poorer cognitive and emotional outcome. Fewer years of education and depressive symptoms predicted greater executive dysfunction. Younger age at injury predicted more aggressive and rule-breaking behaviour. TAI and depressive symptoms predicted Internalizing problems and greater executive dysfunction. In conclusion, age, education, TAI, and depression appear to elevate risk for poor long-term outcome, emphasising the need for long-term follow-up of patients presenting with risk factors.

White matter microstructure in chronic moderate-to-severe traumatic brain injury: Impact of acute-phase injury-related variables and associations with outcome measures.

This study examines how injury mechanisms and early neuroimaging and clinical measures impact white matter (WM) fractional anisotropy (FA), mean diffusivity (MD), and tract volumes in the chronic phase of traumatic brain injury (TBI) and how WM integrity in the chronic phase is associated with different outcome measures obtained at the same time. Diffusion tensor imaging (DTI) at 3 T was acquired more than 1 year after TBI in 49 moderate-to-severe-TBI survivors and 50 matched controls. DTI data were analyzed with tract-based spatial statistics and automated tractography. Moderate-to-severe TBI led to widespread FA decreases, MD increases, and tract volume reductions. In severe TBI and in acceleration/deceleration injuries, a specific FA loss was detected. A particular loss of FA was also present in the thalamus and the brainstem in all grades of diffuse axonal injury. Acute-phase Glasgow Coma Scale scores, number of microhemorrhages on T2*, lesion volume on fluid-attenuated inversion recovery, and duration of posttraumatic amnesia were associated with more widespread FA loss and MD increases in chronic TBI. Episodes of cerebral perfusion pressure <70 mmHg were specifically associated with reduced MD. Neither episodes of intracranial pressure >20 mmHg nor acute-phase Rotterdam CT scores were associated with WM changes. Glasgow Outcome Scale Extended scores and performance-based cognitive control functioning were associated with FA and MD changes, but self-reported cognitive control functioning was not. In conclusion, FA loss specifically reflects the primary injury severity and mechanism, whereas FA and MD changes are associated with objective measures of general and cognitive control functioning.

Accuracy of Self-reported Length of Coma and Posttraumatic Amnesia in Persons With Medically Verified Traumatic Brain Injury

ObjectiveTo determine the accuracy of self-reported length of coma and posttraumatic amnesia (PTA) in persons with medically verified traumatic brain injury (TBI) and to investigate factors that affect self-report of length of coma and PTA duration. DesignProspective cohort study. SettingSpecialized rehabilitation center with inpatient and outpatient programs. ParticipantsPersons (N=242) with medically verified TBI who were identified from a registry of persons who had previously participated in TBI-related research. InterventionNot applicable. Main Outcome MeasuresSelf-reported length of coma and self-reported PTA duration. ResultsReview of medical records revealed that the mean medically documented length of coma and PTA duration was 6.9±12 and 19.2±22 days, respectively, and the mean self-reported length of coma and PTA duration was 16.7±22 and 106±194 days, respectively. The average discrepancy between self-report and medical record for length of coma and PTA duration was 8.2±21 and 64±176 days, respectively. Multivariable regression models revealed that time since injury, performance on cognitive tests, and medical record values were associated with self-reported values for both length of coma and PTA duration. ConclusionsIn this investigation, persons with medically verified TBI showed poor accuracy in their self-report of length of coma and PTA duration. Discrepancies were large enough to affect injury severity classification. Caution should be exercised when considering self-report of length of coma and PTA duration.

Predictors of On-Road Driver Performance Following Traumatic Brain Injury

ObjectiveTo examine assessment outcomes and factors associated with passing an occupational therapy (OT) on-road driver assessment after traumatic brain injury (TBI). DesignRetrospective analysis of outcomes of on-road driver assessment completed by persons with TBI over an 8-year period. SettingInpatient and outpatient rehabilitation hospital. ParticipantsA consecutive sample of individuals (N=207) with mild to severe TBI who completed an on-road driver assessment and were assessed at least 3 months postinjury. InterventionNot applicable. Main Outcome MeasureOutcome of on-road driver assessment. ResultsOf the drivers with TBI, 66% (n=137) passed the initial on-road driver assessment (pass group), whereas 34% (n=70) required on-road driver rehabilitation and/or ≥1 on-road assessment (rehabilitation group). After driver rehabilitation, only 3 participants of the group did not resume driving. Participants who were men, had shorter posttraumatic amnesia (PTA) duration, had no physical and/or visual impairment, and had faster reaction times were significantly more likely to be in the pass group. In combination, these variables correctly classified 87.6% of the pass group and 71.2% of the rehabilitation group. ConclusionsPTA duration proved to be a better predictor of driver assessment outcome than Glasgow Coma Scale score. In combination with the presence of physical/visual impairment and slowed reaction times, PTA could assist clinicians to determine referral criteria for OT driver assessment. On-road driver rehabilitation followed by on-road reassessment were associated with a high probability of return to driving after TBI.

The trajectory of awareness across the first year after traumatic brain injury: The role of biopsychosocial factors

Objective: To examine self-awareness over the first year following traumatic brain injury (TBI) and the association of demographic, biological, cognitive, psychological and social-environmental factors with change in awareness.Research design: Using a longitudinal design the progression of awareness and association of demographic and biopsychosocial factors with its trajectory were analysed using random effects regression.Methods and procedures: Sixty individuals with mainly moderate-to-severe TBI completed assessments at 3, 6 and/or 12 months post-injury. Measures of awareness (Self-Awareness of Deficits Interview; SADI), demographic (age at time of injury and gender), injury severity (post-traumatic amnesia duration), cognitive (Trails Making Test-Part B), psychological (Hospital Anxiety and Depression Scale) and social-environmental (return to pre-injury activities) factors were administered.Main outcomes and results: Awareness improved over the first year post-injury. Analysis of SADI sub-scales revealed that females had greater awareness in terms of setting more realistic goals early in recovery compared to males. Models including demographic, biological, cognitive, psychological and social-environmental factors did not contribute significantly to prediction of awareness on the SADI above the influence of time.Conclusions: Time post-injury had the strongest influence on the development of awareness. This understanding may be important in determining the optimal timing of rehabilitative intervention.

COMT Val158Met and cognitive and functional outcomes after traumatic brain injury.

There is significant variability in long-term outcomes after traumatic brain injury (TBI), making accurate prognosis difficult. In seeking to enhance understanding of outcomes, this study aimed to investigate whether COMT Val(158)Met allele status was associated with performance on neuropsychological measures of attention and working memory, executive functioning, learning and memory, and speed of information processing in the early rehabilitation phase. The study also aimed to examine whether the COMT polymorphism was associated with longer-term functional outcomes. A total of 223 participants (71.3% male) with moderate-to-severe TBI were recruited as rehabilitation inpatients to participate in a prospective, longitudinal head injury outcome study. The three COMT genotype groups (Val/Val, Val/Met, and Met/Met) were well matched for estimated full-scale IQ, years of education, age at injury, and injury severity. Results showed no significant difference between genotypes on neuropsychological measures (all p>0.05) or functional outcome, as measured by the Glasgow Outcome Scale-Extended (GOS-E), after controlling for age, education, and severity of injury. The presence of frontal lobe pathology was also not associated with cognitive performance. Those with greater injury severity (i.e., longer duration of post-traumatic amnesia) performed more poorly on measures of processing speed and verbal new learning and recall. It was concluded that there was little support for the influence of COMT Val(158)Met on cognitive function, or functional outcome measures, in the acute rehabilitation phase after TBI.

INCOG recommendations for management of cognition following traumatic brain injury, part I: posttraumatic amnesia/delirium.

After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA. The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study. The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

Comorbidity and Insurance as Predictors of Disability After Traumatic Brain Injury

ObjectiveTo examine the unique contribution of self-reported medical comorbidity and insurance type on disability after traumatic brain injury (TBI). DesignInception cohort design at 1-year follow up. SettingA university affiliated rehabilitation hospital. ParticipantsAdults with mild-complicated to severe TBI (N=70). InterventionNot applicable. Main Outcome MeasuresSelf-reported medical comorbidities were measured using the Modified Cumulative Illness Rating Scale, while insurance type was classified as commercial or government-funded; disability was measured using the Disability Rating Scale. ResultsTwo models were run using multiple linear regression, and the best-fitting model was selected on the basis of Bayesian information criterion. The full model, which included self-reported medical comorbidity and insurance type, was significantly better fitting than the reduced model. Participants with a longer duration of posttraumatic amnesia, more self-reported medical comorbidities, and government insurance were more likely to have higher levels of disability. Meanwhile, individual organ systems were not predictive of disability. ConclusionsThe cumulative effect of self-reported medical comorbidities and type of insurance coverage predict disability above and beyond well-known prognostic variables. Early assessment of medical complications and improving services provided by government-funded insurance may enhance quality of life and reduce long-term health care costs.

Structural Integrity of Medial Temporal Lobes of Patients with Acute Mild Traumatic Brain Injury

Post-traumatic amnesia (PTA) is an acute characteristic of traumatic brain injury (TBI) and the duration of PTA is commonly used to estimate the severity of brain injury. In the context of mild traumatic brain injury (MTBI), PTA is an essential part of the routine clinical assessment. Macroscopic lesions in temporal lobes, especially hippocampal regions, are thought to be connected to memory loss. However, conventional neuroimaging has failed to reveal neuropathological correlates of PTA in MTBI. Texture analysis (TA) is an image analysis technique that quantifies the minor MRI signal changes among image pixels and, therefore, the variations in intensity patterns within the image. The objective of this work was to apply the TA technique to MR images of MTBI patients and control subjects, and to assess the microstructural damage in medial temporal lobes of patients with MTBI with definite PTA. TA was performed for fluid-attenuated inversion recovery (FLAIR) images of 50 MTBI patients and 50 age- and gender-matched controls in the regions of the amygdala, hippocampus, and thalamus. It was hypothesized that 1) there would be statistically significant differences in TA parameters between patients with MTBIs and controls, and 2) the duration of PTA would be related to TA parameters in patients with MTBI. No significant textural differences were observed between patients and controls in the regions of interest (p>0.01). No textural features were observed to correlate with the duration of PTA. Subgroup analyses were conducted on patients with PTA of>1 h, (n=33) and compared the four TA parameters to the age- and gender-matched controls (n=33). The findings were similar. This study did not reveal significant textural changes in medial temporal structures that could be related to the duration of PTA.

Frequency and Quality of Return to Study Following Traumatic Brain Injury

To examine the frequency and experience of return to secondary or tertiary study over a 10-year period following traumatic brain injury (TBI). A group of 295 students with moderate to severe TBI followed prospectively. Epworth HealthCare TBI outpatient rehabilitation program follow-up clinic 1 to 10 years postinjury. Frequency of return to study. Also, for a subset, changes in course enrollment, utilization of additional educational supports, and experience of return to study postinjury. Of those studying preinjury, 295 attended the follow-up clinic appointments, with 167 (56%) having returned to study. Those who did not return to study had significantly longer posttraumatic amnesia duration. The cross-sectional follow-up revealed that 60.4% were studying at 1 year postinjury, 37.5% at 2 years postinjury, 50.0% at 3 years postinjury, 31.1% at 5 years postinjury, and 2.0% at 10 years postinjury. Many had migrated into employment. A subsample of 95 participants reported on their educational experience. Of those, 28.7% changed their course enrollment from full-time to part-time. While supports such as tuition and special consideration were greatly increased postinjury, students reported the proportion of subjects passed of 79.0%. However, they experienced cognitive difficulties and fatigue and felt less satisfied with their studies. Return to study was relatively successful; however, this was associated with the experience of fatigue and need for far greater effort, assistance and reduced study hours, and somewhat less overall satisfaction.

Prevalence, Comorbidities, and Correlates of Challenging Behavior Among Community-Dwelling Adults With Severe Traumatic Brain Injury

Investigate the prevalence, comorbidities, and correlates of challenging behaviors among clients of the New South Wales Brain Injury Rehabilitation Program. All community-based rehabilitation services of the statewide program. Five hundred seven active clients with severe traumatic brain injury. Prospective multicenter study. Eighty-eight clinicians from the 11 services rated clients on the Overt Behaviour Scale, Disability Rating Scale, Sydney Psychosocial Reintegration Scale-2, Care and Needs Scale, and Health of the Nation Outcome Scale-Acquired Brain Injury. Overall prevalence rate of challenging behaviors was 54%. Inappropriate social behavior (33.3%), aggression (31.9%), and adynamia (23.1%) were the 3 most common individual behaviors, with 35.5% of the sample displaying more than 1 challenging behavior. Significant associations were found between increasing levels of challenging behavior and longer duration of posttraumatic amnesia, increasing functional disability, greater restrictions in participation, increased support needs, and greater degrees of psychiatric disturbance, respectively (P < 0.004). Multivariate binomial logistic regression found that premorbid alcohol abuse, postinjury restrictions in participation, and higher levels of postinjury psychiatric disturbance were independent predictors of challenging behavior. Challenging behaviors are widespread among community-dwelling adults with severe traumatic brain injury. Services need to deliver integrated anger management, social skills, and motivational treatments.

Early Trajectory of Psychiatric Symptoms after Traumatic Brain Injury: Relationship to Patient and Injury Characteristics

Psychiatric disturbance is common and disabling after traumatic brain injury (TBI). Few studies have investigated the trajectory of psychiatric symptoms in the first 6 months postinjury, when monitoring and early treatment might prevent persistent difficulties. The aim of this study was to examine the trajectory of psychiatric symptoms 1-6 months post-TBI, the patient/injury characteristics associated with changes, and characteristics predictive of persisting symptoms. A secondary analysis was performed on data from a clinical trial with three data collection points. Across eight centers, 872 participants with complicated mild to severe TBI were administered the Brief Symptom Inventory (BSI) at 30, 90, and 180 days postinjury. Mixed-effects models were used to assess longitudinal changes in the BSI Global Severity Index (GSI). Multi-variate logistic regression was used to assess predictors of clinically significant GSI elevations persisting to 6 months post-TBI. In general, GSI scores improved over time. Women improved faster than men; race/ethnicity was also significantly associated with rate of change, with Hispanics showing the most and African Americans the least improvement. Clinically significant psychiatric symptoms (caseness) occurred in 42% of the sample at 6 months, and more than one type of symptom was common. Significant predictors of caseness included African American race, age from 30 to 60 years, longer post-traumatic amnesia (PTA) duration, pre-TBI unemployment, and pre-TBI risky alcohol use. Findings indicate that psychiatric symptoms are common in the first 6 months post-TBI and frequently extend beyond the depression and anxiety symptoms that may be most commonly screened. Patients with longer PTA and preinjury alcohol misuse may need more intensive monitoring for symptom persistence.

Prospective longitudinal MRI study of brain volumes and diffusion changes during the first year after moderate to severe traumatic brain injury.

The objectives of this prospective study in 62 moderate–severe TBI patients were to investigate volume change in cortical gray matter (GM), hippocampus, lenticular nucleus, lobar white matter (WM), brainstem and ventricles using a within subject design and repeated MRI in the early phase (1–26 days) and 3 and 12 months postinjury and to assess changes in GM apparent diffusion coefficient (ADC) in normal appearing tissue in the cortex, hippocampus and brainstem. The impact of Glasgow Coma Scale (GCS) score at admission, duration of post-traumatic amnesia (PTA), and diffusion axonal injury (DAI) grade on brain volumes and ADC values over time was assessed. Lastly, we determined if MRI-derived brain volumes from the 3-month scans provided additional, significant predictive value to 12-month outcome classified with the Glasgow Outcome Scale—Extended after adjusting for GCS, PTA and age.Cortical GM loss was rapid, largely finished by 3 months, but the volume reduction was unrelated to GCS score, PTA, or presence of DAI. However, cortical GM volume at 3 months was a significant independent predictor of 12-month outcome. Volume loss in the hippocampus and lenticular nucleus was protracted and statistically significant first at 12 months. Slopes of volume reduction over time for the cortical and subcortical GGM were significantly different. Hippocampal volume loss was most pronounced and rapid in individuals with PTA > 2 weeks. The 3-month volumes of the hippocampus and lentiform nucleus were the best independent predictors of 12-month outcome after adjusting for GCS, PTA and age. In the brainstem, volume loss was significant at both 3 and 12 months. Brainstem volume reduction was associated with lower GCS score and the presence of DAI. Lobar WM volume was significantly decreased first after 12 months. Surprisingly DAI grade had no impact on lobar WM volume. Ventricular dilation developed predominantly during the first 3 months, and was strongly associated with volume changes in the brainstem and cortical GM, but not lobar WM volume.Higher ADC values were detected in the cortex in individuals with severe TBI, DAI and PTA > 2 weeks, from 3 months. There were no associations between ADC values and brain volumes, and ADC values did not predict outcome.

Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury.

The study objective was to examine postacute changes in bowel and bladder continence and cognition after severe traumatic brain injury (TBI) in persons with long-term functional recovery to full independence. This case series included nine patients initially admitted to inpatient rehabilitation (IR) with severe TBI who had returned to prior responsibilities and functional independence by 8 to 15 mo. Patients had initial Glasgow Coma Scale scores of 3 to 6, posttraumatic amnesia durations of 18 to 70 d, time-to-follow-commands of 16 to 56 d, initial abnormal brain computed tomography scans, and initial pupil abnormalities. IR Functional Independence Measure (FIM) cognitive and sphincter score improvements were compared with national TBI FIM data from Uniform Data Systems for Medical Rehabilitation (UDSMR) for 2010 (n = 16,368). All patients had IR improvements in cognitive and sphincter FIM scores approximately twice the national UDSMR data for 2010. All patients had combined IR discharge sphincter FIM scores that were 12 or greater, indicating independence to modified independence with bowel and bladder function with no incontinence. Five participants (55%) were admitted to IR with sphincter FIM scores of 11 to 12, indicating recovery of continence during acute care. These findings suggest potential usefulness of IR cognitive FIM score changes and of the recovery of bowel and bladder continence for predicting favorable functional outcomes following severe TBI.

Structural integrity of medial temporal lobes of patients with acute mild traumatic brain injury

Post-traumatic amnesia (PTA) is an acute characteristic of traumatic brain injury (TBI) and the duration of PTA is commonly used to estimate the severity of brain injury. In the context of mild traumatic brain injury (MTBI), PTA is an essential part of the routine clinical assessment. Macroscopic lesions in temporal lobes, especially hippocampal regions, are thought to be connected to memory loss. However, conventional neuroimaging has failed to reveal neuropathological correlates of PTA in MTBI. Texture analysis (TA) is an image analysis technique that quantifies the minor MRI signal changes among image pixels and, therefore, the variations in intensity patterns within the image. The objective of this work was to apply the TA technique to MR images of MTBI patients and control subjects, and to assess the microstructural damage in medial temporal lobes of patients with MTBI with definite PTA. TA was performed for fluidattenuated inversion recovery (FLAIR) images of 50 MTBI patients and 50 age- and gender-matched controls in the regions of the amygdala, hippocampus, and thalamus. It was hypothesized that 1) there would be statistically significant differences in TA parameters between patients with MTBIs and controls, and 2) the duration of PTA would be related to TA parameters in patients with MTBI. No significant textural differences were observed between patients and controls in the regions of interest (p >0.01). No textural features were observed to correlate with the duration of PTA. Subgroup analyses were conducted on patients with PTA of >1h, (n =33) and compared the four TA parameters to the age- and gender-matched controls (n =33). The findings were similar. This study did not reveal significant textural changes in medial temporal structures that could be related to the duration of PTA.

Costs of Care after Traumatic Brain Injury

Traumatic brain injuries (TBI) impose a significant burden on the health care system. The aim of the current study was to explore variation in costs in a group of rehabilitation patients in Victoria, Australia, following complicated mild-to-severe TBI treated under the accident compensation system administered by the Transport Accident Commission. Study participants included 1237 individuals with mild-to-severe TBI recruited consecutively from a TBI rehabilitation program. Long-term care, hospital, medical, and paramedical costs were obtained 10 years post-injury and their association with demographic and injury-related variables were examined. Significant variability in costs was evident. Long-term care costs were highest, followed by hospital, paramedical, and medical costs. Duration of post-traumatic amnesia (PTA) was a strong predictor of all costs, and stronger than Glasgow Coma Score (GCS). Longer acute hospital stay was related to higher costs. In addition to PTA duration and GCS, other factors associated with higher long-term costs were having an abnormal CT scan and epilepsy early after injury. Higher hospital and medical costs were associated with these factors, but also with other physical injuries, lower education, pre-injury unemployment, living outside the city, speaking English at home, and, in the case of medical costs, older age and having had pre-injury psychiatric treatment. Higher paramedical costs were associated with most of these variables, but also with being employed prior to injury and being female. In line with the multifaceted nature of TBI, the current findings suggest that both injury-related and demographic factors determine costs following injury.

Factors Associated With Sexuality Following Traumatic Brain Injury

Previous research has demonstrated that sexuality is compromised following traumatic brain injury (TBI). The aim of this study was to determine the association between sexuality following TBI and demographic, injury-related, and postinjury variables (age, gender, time since injury, posttraumatic amnesia duration, independence in activities of daily activities (ADL), antidepressant use, depression, and self-esteem). Participants included 986 individuals with predominantly moderate to severe TBI, who completed the Brain Injury Questionnaire of Sexuality (BIQS), the Hospital Anxiety and Depression Scale, and the Rosenberg Self-Esteem Scale and an ADL assessment on 1 or more occasions, providing a total of 1673 assessments across 1, 2, 3, 5, 10, and 20 years postinjury. Being depressed, older in age, at shorter time postinjury, and less independent in ADL significantly predicted poorer overall BIQS scores as well as the Sexual Functioning subscale score. Poorer Relationship Quality and Self-esteem scores on the BIQS were predicted by older age at injury and higher levels of depression. Lower Mood score on the BIQS was associated with shorter posttraumatic amnesia duration, younger age, and higher levels of depression. Self-esteem was associated positively with sexuality outcome. Therapeutic interventions for sexuality need to focus on depression where indicated and self-esteem and address specific barriers to social participation and opportunities for sexual contact in individuals who are less independent in ADL.

Prediction of headache severity (density and functional impact) after traumatic brain injury: A longitudinal multicenter study

Headache (HA) following traumatic brain injury (TBI) is common, but predictors and time course are not well established, particularly after moderate to severe TBI. A prospective, longitudinal cohort study of HA severity post-TBI was conducted on 450 participants at seven participating rehabilitation centers. Generalized linear mixed-effects models (GLMMs) were used to model repeated measures (months 3, 6, and 12 post-TBI) of two outcomes: HA density (a composite of frequency, duration, and intensity) and HA disruptions to activities of daily living (ADL). Although HA density and ADL disruptions were nominally highest during the first three months post-TBI, neither showed significant changes over time. At all time points, history of pre-injury migraine was by far the strongest predictor of both HA density and ADL disruptions (odds ratio (OR) = 8.0 and OR = 7.2, averaged across time points, respectively). Furthermore, pre-injury non-migraine HA (at three and six months post-TBI), penetrating-type TBI (at six months post-TBI), and female sex (at six and 12 months post-TBI) were each associated with an increase in the odds of a more severe HA density. Severity of TBI (post-traumatic amnesia (PTA) duration) was not associated with either outcome. Individuals with HA at three months after moderate-severe TBI do not improve over the ensuing nine months with respect to HA density or ADL disruptions. Those with pre-injury HA, particularly of migraine type, are at greatest risk for HA post-TBI. Other independent risk factors are penetrating-type TBI and, to a lesser degree and post-acutely only, female sex. Individuals with these risk factors should be monitored and considered for aggressive early intervention.

Variabilidad interindividual en la recuperación después de un traumatismo craneoencefálico: efecto de la reserva cognitiva

Background and objectiveThe aim of this study was to examine the effect of cognitive reserve in recovery after a moderate or severe traumatic brain injury (TBI). Different authors proposed that this construct might account for the mismatch between TBI severity, its clinical expression, and subsequent recovery. Patients and methodEighty-four patients who sustained moderate-to-severe TBI participated in the study. Participants were divided into a high cognitive reserve group (n=46) or low cognitive reserve group (n=38) based on premorbid educational and occupational attainment. Patient's functional status was examined with the Patient Competency Rating Scale (PCRS). ResultsThere were no significant differences between groups in demographic and injury variables (sex, age, severity of injury, post-traumatic amnesia duration, and time since injury). The analysis revealed statistically significant differences between the 2 groups on the PCRS: The high cognitive reserve group scored better than the low cognitive reserve group. ConclusionsThe results of this study suggest that cognitive reserve may mediate recovery after a moderate or severe TBI. Educational and occupational attainments provide a cognitive provision that would be associated with better functional status after injury.