Post-injury Assessments Research Articles

Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children

Objective: To examine the contributions of injury severity, physical and cognitive disability, child and family function to outcome 30 months after traumatic brain injury (TBI) in children. Design: A prospective,...

Depression in older people after fall-related injuries: a prospective study.

objectives of the study were i) to describe changes in depression in independently living people aged 57 or older with fall-related injuries, and ii) to examine the effect of incomplete recovery of physical functions on depression one year post-injury. prospective cohort-study, including a pre-injury baseline and post-injury assessments at 8 weeks, 5 months and one year. The sample consisted of 159 patients who sustained various kinds of fall-related injuries to the limbs. Physical functioning was measured by the Groningen Activity Restriction Scale, depression by the Hospital Anxiety and Depression Scale. Additional variables in the study were age, gender, chronic medical conditions and severity of the injury (three level-groups). Pre- and post-injury levels of depression were compared by using Student's t-test and effect size indices. Hierarchical multivariate regression analysis was used to examine the contribution of change in physical functioning between baseline and one year post-injury to depression one year post-injury. severity of the injury was not associated with depression. Mean depression levels of all patients remained stable until 5 months post-injury but increased between 5 months and one year. Physical functioning decreased between baseline and 8 weeks post-injury, increased between 8 weeks and 5 months but did not change after 5 months. One year post-injury, both disability and depression were higher than at baseline. Change in physical functioning between baseline and one year post-injury accounted for 19% of the variance in depression explained by the regression model. depressive reactions did not occur as long as patients experienced improvement in physical functioning but became manifest as recovery appeared to stagnate. No significant differences in this respect were found between hip fracture patients and patients with other injuries.

Assessment of cognitive recovery following sports related head trauma in boxers.

To prospectively examine recovery of cognitive function within one month following subconcussive sports related head trauma. A prospective study of New York State licensed professional boxers who underwent testing of cognitive functioning before and after (within days, one week, and one month) a professional bout. Male professional athletes recruited from the New York State Athletic Commission and local boxing gyms. Twenty-six licensed professional boxers were enrolled in the protocol. Data is presented on the 18 participants who completed testing on at least three of the four time points. Serial neuropsychological assessment before and after the athletes engaged in competition. Neuropsychological measures of cognitive functioning, including new learning and memory, information processing speed, and mental flexibility. A series of repeated measures MANOVAS revealed significant within subject differences across testing on complex information processing and verbal fluency. Post hoc analyses indicated significant differences between time 1 (baseline) and time 4 (one month post), with scores one month following the bout indicating significantly improved performance. Memory scores did not change significantly across testing; however, prior boxing exposure measured by total number of professional bouts was associated with poorer memory performance. Cognitive testing one month following participation in a professional boxing bout yielded scores suggestive of recovery to a level above the baseline. We conclude that baseline assessment taken during periods of intense training are likely confounded by other pre-bout conditions (i.e., sparring, rapid weight loss, pre-bout anxiety) and do not represent true baseline abilities. Instability of performance associated with mild head injury may complicate the interpretation of post-injury assessments. Practice effects may also confound the interpretation of serial assessments, leading to underestimation of the effects of sports related head trauma. Poorer cognitive performance was evident during the presumed recovery period in boxers with greater exposure to the sport (>12 professional bouts). This finding is consistent with reports of a cumulative effect of repetitive head trauma and the subsequent development of chronic traumatic brain injury. These data have implications for assessing recovery of function following head injury in players of other contact sports as well as determination of return-to-play following an injury.

Health-related quality of life of children and adolescents after traumatic brain injury.

Relatively little is known about the longer-term impact of traumatic brain injury (TBI) on children's daily functioning, especially the broader outcome domain referred to as health-related quality of life (HRQL). The objective of the present study was to examine the nature and predictors of HRQL outcomes in children with moderate to severe TBI an average of 4 years postinjury. The study used a concurrent cohort-prospective design involving postinjury assessments of 3 groups of traumatically injured children and their families including 42 with severe TBI, 42 with moderate TBI, and 50 with orthopedic injuries only. Parent and child perceptions of HRQL and child adaptive behavior measures were obtained along with parent descriptions of the child's health problems and use of medical and mental health services. Predictors included indices of injury severity, social factors, and ratings of preinjury child behavior problems and school performance. Based on parent report, adolescents who sustained severe TBI had lower HRQL related to overall psychosocial functioning and in the domains of behavior, mental health, general health, and family impact than adolescents who sustained orthopedic injuries only. Communication skills, daily living skills, and general adaptive functioning also were rated lower in the severe TBI group. In contrast to parent reports, adolescents with severe TBI did not rate their HRQL in most domains differently than did adolescents with orthopedic injuries. There were no group differences in frequency of persistent physical limitations. Sixty-seven percent of families of children with severe TBI used mental health counseling at some point after the injury. Risks for poorer HRQL outcomes were related to family social disadvantage and poorer preinjury child behavioral and academic functioning. Findings underscore the importance of using comprehensive measures of HRQL, along with traditional indicators of functional outcomes, when evaluating the longer-term impact of injuries in children. Identification of predictors suggests the need for close monitoring and intervention of high-risk children.

The novel calpain inhibitor SJA6017 improves functional outcome after delayed administration in a mouse model of diffuse brain injury.

A principal mechanism of calcium-mediated neuronal injury is the activation of neutral proteases known as calpains. Proteolytic substrates for calpain include receptor and cytoskeletal proteins, signal transduction enzymes and transcription factors. Recently, calpain inhibitors have been shown to provide benefit in rat models of focal head injury and focal cerebral ischemia. The present study sought to investigate, in experiment 1, the time course of calpain-mediated cytoskeletal injury in a mouse model of diffuse head injury by measuring the 150- and 145-kDa alpha-spectrin breakdown products (SBDP). Secondly, in experiment 2, we examined the effect of early (20 min postinjury) administration of the novel calpain inhibitor SJA6017 on functional outcome measured 24 h following injury and its effect on posttraumatic alpha-spectrin degradation. Lastly, in experiment 3, we examined the effect of delayed (4 or 6 h postinjury) administration of SJA6017 on 24-h postinjury functional outcome. In experiment 1, isoflurane-anesthetized male CF-1 mice (18-22 g) were subjected to a 750 g-cm weight drop-induced injury and were sacrificed for SBDP analysis at postinjury times of 30 min, and 1, 2, 6, 24 and 48 h (plus sham). In experiments 2 and 3, mice were injured as described, and delivered a single tail vein injection of either SJA6017 (0.3, 1, or 3 mg/kg) or vehicle (administered immediately, 4 or 6 h postinjury [3 mg/kg]). Functional outcome was evaluated in both studies, and, in experiment 2, 24-h postinjury assessment of SBDPs was determined. Following injury, the level of SBDP 145 was significantly different from sham at 24 and 48 h in cortical and at 24 h in the hippocampal tissues and at 48 h in the striatum. Immediate postinjury administration of SJA6017 resulted in a dose-related improvement in 24-h functional outcome (p < 0.05 at 3 mg/kg). Significance was maintained after a 4-h delay of the 3 mg/kg, but was lost after a 6-h delay. Despite improvement in functional outcome at 24 h, SJA6017 did not reduce spectrin breakdown in cortical or hippocampal tissues. These results support a role for calpain-mediated neuronal injury and the potential for a practical therapeutic window for calpain inhibition following traumatic brain injury. However, measurements of regional spectrin degradation may not be the most sensitive marker for determining the effects of calpain inhibition.

Recovery of physical function after limb injuries in independent older people living at home.

to describe changes in physical functioning after fall-related injuries to the limbs in independently living older people. prospective cohort study, including a pre-injury assessment and post-injury assessments at 8 weeks and 5 and 12 months. the study is part of the larger, population-based prospective and longitudinal Groningen Longitudinal Aging Study on the determinants of health-related quality of life of people aged 57 and over, who are living independently in the north of the Netherlands. 171 patients who sustained injuries at various sites on the limbs and who had completed all four assessments (66% of the eligible population). Patients were grouped according to injury site. self-reported grades of difficulties with performing basic and instrumental activities of daily living as measured by the Groningen Activity Restriction Scale. 1 year after the injury, pre-injury (mean) levels of functioning were not regained in any of the groups studied. However, only those with fractures of the wrist or hip experienced a substantial decrease in ability to perform basic and instrumental activities of daily living between baseline and the final assessment. Furthermore, of the 44 subjects with wrist fractures, seven (15.9%) needed help with at least one relevant activity at baseline and 18 (40.9%) at 12 months. Of the 34 subjects with hip fractures, four (11.8%) needed help with at least one activity at baseline and 18 (52.9%) at 12 months. Practically no changes were found in any of the groups after 5 months post-injury. not only hip fractures, but also wrist fractures may reduce older people's chances of remaining independent. Prospects of further recovery are minimal 5-6 months after the injury.

Hierarchical linear modeling of FIM instrument growth curve characteristics after spinal cord injury

Warschausky S, Kay JB, Kewman DG. Hierarchical linear modeling of FIM instrument growth curve characteristics after spinal cord injury. Arch Phys Med Rehabil 2001;82:329-34. Objective: To examine the recovery of aspects of functional independence as a continuous process using growth curve analysis. Design: Retrospective database review of functional outcome assessment data from inception cohort. Setting: Inpatient rehabilitation unit; community. Patients: A total of 142 subjects (79.6% men; age range, 18-77yr; mean age ± standard deviation, 36.2 ± 15.5yr) who were admitted to a rehabilitation unit between March 1986 and November 1994 with a minimum of 4 postinjury FIM™ assessments. Neurologic subgroups included 63 individuals with paraplegia, 36 with low tetraplegia, 24 with high tetraplegia, and 19 with incomplete injury. Main Outcome Measure: FIM instrument. Results: Growth curve analyses with hierarchial linear modeling using a decelerating recovery function yielded a reliable model in which longer rehabilitation length of stay was associated with a more rapid rate of recovery but lower plateau. Neurologic injury category had expected effects on rate and degree of recovery. Level of impairment-specific results included an age effect in which older age was associated with lower level of plateau. In specific neurologic groups there was a significant gender effect, in which men made more rapid recovery than women, and a significant effect of level of education, in which higher education was associated with more rapid rate of recovery. Rate of FIM recovery was reliably modeled in the sample with incomplete injuries, but none of the demographic predictors was significant. Conclusions: Functional recovery can be modeled as a decelerating rather than simple linear function. The study of predictors of recovery characteristics, including rate of recovery and plateau, offers a valuable way of understanding rehabilitative needs and outcomes. Gender and education effects on the recovery process are intriguing and warrant further investigation.

Postinjury Administration of [formula omitted]-Deprenyl Improves Cognitive Function and Enhances Neuroplasticity after Traumatic Brain Injury

The rat model of combined central fluid percussion traumatic brain injury (TBI) and bilateral entorhinal cortical lesion (BEC) produces profound, persistent cognitive deficits, sequelae associated with human TBI. In contrast to percussive TBI alone, this combined injury induces maladaptive hippocampal plasticity. Recent reports suggest a potential role for dopamine in CNS plasticity after trauma. We have examined the effect of the dopamine enhancer l-deprenyl on cognitive function and neuroplasticity following TBI. Rats received fluid percussion TBI, BEC alone, or combined TBI + BEC lesion and were treated once daily for 7 days with l-deprenyl, beginning 24 h after TBI alone and 15 min after BEC or TBI + BEC. Postinjury motor assessment showed no effect of l-deprenyl treatment. Cognitive performance was assessed on days 11–15 postinjury and brains from the same cases examined for dopamine β-hydroxylase immunoreactivity (DBH-IR) and acetylcholinesterase (AChE) histochemistry. Significant cognitive improvement relative to untreated injured cases was observed in both TBI groups following l-deprenyl treatment; however, no drug effects were seen with BEC alone. l-Deprenyl attenuated injury-induced loss in DBH-IR over CA1 and CA3 after TBI alone. However, after combined TBI + BEC, l-deprenyl was only effective in protecting CA1 DBH-IR. AChE histostaining in CA3 was significantly elevated with l-deprenyl in both injury models. After TBI + BEC, l-deprenyl also increased AChE in the dentate molecular layer relative to untreated injured cases. These results suggest that dopaminergic/noradrenergic enhancement facilitates cognitive recovery after brain injury and that noradrenergic fiber integrity is correlated with enhanced synaptic plasticity in the injured hippocampus.

Examination of a Clinical method of Assessing Postural Control during a Functional Performance Task

Postural control and functional performance tests are often used separately during orthopedic postinjury assessments. The purpose of this investigation was to examine a clinical method of assessing postural control during a functional performance task. Thirty participants were divided into two groups. The first group was tested three times, the second group only once. The same tester evaluated each participant's performance during all testing sessions, and during the first two testing sessions (Group 1) two additional testers evaluated each performance. Intraclass correlational coefficients between the three testers ranged from .70 to .92. Session 1 (Group 1) scores were pooled with Group 2 scores, and correlational analyses were conducted between participant height and performance; no significant relationships were revealed. The scores from Group 1 were analyzed using between-days repeated-measures ANOVAs. Results revealed significant improvement between Sessions 1 and 3 for the static portion of the test. The results suggest that the multiple single-leg hop-stabilization test offers a method of assessing postural control during a functional performance task.

Assessing disability after head injury: improved use of the Glasgow Outcome Scale.

The Glasgow Outcome Scale (GOS) is widely used to assess outcome after head injury, but is recognized as having a number of shortcomings that are highlighted and investigated in this study. The authors pursued two goals: 1) investigating the practicality of using a standard set of questions as part of a structured interview to assign GOS scores, and 2) studying the role of preinjury problems in confounding postinjury assessment of disability. Several of the major limitations of the GOS appear to arise from the use of a format that encourages impressionistic ratings. In the present study the authors examined the use of a standard interview for assessing the GOS covering five areas of social disability. Ratings were made for 80 head-injured patients. The results show that the rating based on the GOS provides an assessment of disability that is more complete than that given by an alternative scale of functional disability (Disability Rating Scale [DRS]) and much more complete than an assessment of physical disability (Barthel Activities of Daily Living [ADL] index). A measure of preinjury dependency was made revealing that, within this sample, 20% of patients required supervision in basic ADL before their injury. Assignment of GOS scores based on information obtained using a structured interview format provides a more comprehensive assessment of disability than using the DRS or the ADL index. There is a need to standardize attitudes about preinjury dependency in assessing disability after head injury.

Academic placement after traumatic brain injury

The academic placement of 87 children 6 years 6 months to 16 years 6 months old who had sustained traumatic brain injuries was determined within 1 year after injury. Forty-five children had returned full-time to regular academic programs, 21 children were receiving special education support for less than 50% of their classes, and 21 children were enrolled in special education classes for more than 50% of their time. The predictive power of various patient history variables with regard to school reentry was evaluated by means of stepwise discriminant analysis. Verbal IQ at initial postinjury assessment appeared to be the most important factor with regard to school placement within the first year after injury. Theoretical and research implications are discussed.

Prediction of long-term cognitive outcome of brain injury with neuropsychological, severity of injury, and demographic data.

A comparison was made of the relative power of a brief post-injury neuropsychological assessment and a brain-injury severity measure (PTA) to predict long-term cognitive outcome after severe brain injury. Subjects were 78 patients with severe brain injury. Regression analysis revealed that neuropsychological variables were as predictive of outcome as PTA. A combination of neuropsychological, brain-injury severity, and demographic variables predicted a substantial proportion of variance in both general cognitive ability and memory functioning at outcome. Removal of PTA from the set of predictors had only modest impact on predictive power, suggesting that, in the absence of accurate injury severity data, meaningful prediction about long-term cognitive outcome can still be made.