Subsequent Long-term Disability Research Articles

Post-concussion symptoms 1-year after traumatic brain injury: using the Rivermead Post-concussion Questionnaire to identify predictors of severity

ABSTRACT Background Patients who suffer traumatic brain injury (TBI) often experience a constellation of physical, cognitive, and emotional/behavioral symptoms called “post-concussion symptoms” and subsequent long-term disability. This study aimed to investigate the incidence of persistent post-concussion symptoms and possible predictors of long-term disability focusing on demographic, injury, and psychological factors. It was hoped to identify groups at high risk. Methods A prospective cohort of 1322 individuals admitted with TBI were assessed in a specialist neurorehabilitation clinic at 10 weeks and 1-year post injury between August 2011 and July 2015. The outcome (post-concussion symptoms) was measured using the Rivermead Post-concussion Questionnaire (RPQ) at 1-year post injury. Results At 1 yr, 1131 individuals were identified (>90% follow-up). Over 20% exhibited moderate or severe symptom levels on RPQ. A linear regression model showed that previous psychiatric history, lower Glasgow Coma Scale (GCS), severe CT abnormalities, injury caused by assault, pre-injury unemployment, and inability to return to work at 6 weeks post-injury were associated with worse symptoms at 1 yr. The adjusted R2 of the model was 25.1%. Conclusion These findings confirm the high incidence of post-concussion symptoms at 1 yr and identify certain associated features that increase risk. This may allow targeting of certain groups, e.g., return to work or victims of assault.

Medical Emergencies in Farmers.

Agricultural work involves hazards that may harm long-term well-being. We evaluated the risk of long-term disability and death for agricultural workers compared to construction workers with similar demographics. We hypothesized that delays to emergency care and subsequent long-term disability following injury might be worse for agricultural workers compared to those injured in construction. We evaluated all adults severely injured on farms or on construction sites in Ontario, Canada, between April 1, 2009, and March 31, 2012, according to the Ontario Trauma Registry. We excluded individuals living outside of the province, those missing a valid health card number, or youth less than 17 years old. Our primary outcome was death or the subsequent application for disability support. In total, 353 patients were injured on a farm or construction site during the study period. Delays to emergency care exceeding 12 hours were more frequent for agricultural workers compared to construction workers (43% vs 23%, P <.001). After a 5-year follow-up, agricultural workers had a death or disability rate marginally higher than construction workers (23% vs 14%, P = .068), equivalent to a hazard ratio of 1.62 that was marginally statistically significant (95% confidence interval 0.96-2.75, P = .072). The risk of death and disability was greatest for patients who had the longest delays to emergency care. Agricultural workers experience a substantial delay in receiving emergency care and a marginally higher risk of death or disability in the years following injury compared to construction workers.

Relapse May Serve as a Mediator Variable in Longitudinal Outcomes in Multiple Sclerosis.

Contrast-enhancing lesions (CEL) on magnetic resonance imaging (MRI) are believed to represent inflammatory disease activity in multiple sclerosis (MS), but their relationship to subsequent long-term disability and progression is unclear, particularly at longer time periods such as 8-10 years. Between 1989 and 1994, 111 MS patients were seen at the National Institutes of Health for clinical evaluations and 3 monthly contrast-enhanced MRI scans. Of these, 94 patients were re-evaluated a mean of 8 years later (range 6.1-10.5 years) with a single MRI scan and clinical evaluation. CEL number and volume were determined at baseline and follow-up. The number of relapses was ascertained over the follow-up period and annualized relapse rates were calculated. Other MRI parameters, such as T2 hyperintensity volume, T1 volume, and brain parenchymal fraction, were also calculated. While there was no direct correlation between CEL number or volume at baseline and disability status at follow-up, CEL measures at baseline did correlate with number of relapses observed in the subsequent years, and the number of relapses in turn correlated with subsequent disability as well as transition to progressive MS. While number and volume of CEL at baseline do not directly correlate with disability in the longer term in MS, our data suggest that 1 route to disability involves relapses as a mediator variable in the causal sequence of MS progression from CEL to disability. Further studies using relapse as a mediator variable in a larger data set may be warranted.

Kinematic analysis of the upper extremity after stroke – how far have we reached and what have we grasped?

Background:Consequences of stroke frequently comprise reduced movement ability of the upper extremity (UE) and subsequent long-term disability. Clinical scales are used to monitor and evaluate rehabilitation but are often insufficient, while technological advances in 3D motion capture provide detailed kinematics to more objectively quantify and interpret movement deficits.Objectives:To provide a comprehensive overview of research using kinematic movement analysis of the UE in individuals post-stroke with focus on objectives, methodology and findings while highlighting clinical implications and future directions.Major Findings:A literature search yielded 93 studies categorised into four groups: comparative (healthy, stroke, task condition), intervention (clinical trials), methodological and longitudinal. The majority of studies used optoelectronic systems, investigated discrete reaching and involved mainly individuals with moderate or mild stroke impairment in chronic stage. About 80% of the studies were published after year 2004. Speed-related variables were most frequently addressed followed by smoothness indicators, joint angles and trunk displacement. Movements in the hemiparetic side are generally slower, less smooth and show a compensatory movement pattern. Task specificity is crucial for kinematic outcomes. Tables summarising the main characteristics, objectives and results of all included studies are provided.Conclusions:There is still a lack of studies addressing reliability and responsiveness and involving more complex, everyday UE tasks with ecological validity. To facilitate the use of UE kinematic movement analysis in clinics, a research-based simpler data handling with pre-defined output for the results, as commonly used in gait analysis, is warranted.

Delirium in the ICU and Subsequent Long-Term Disability Among Survivors of Mechanical Ventilation*

Survivors of critical illness are frequently left with long-lasting disability. The association between delirium and disability in critically ill patients has not been described. We hypothesized that the duration of delirium in the ICU would be associated with subsequent disability and worse physical health status following a critical illness. Prospective cohort study nested within a randomized controlled trial of a paired sedation and ventilator weaning strategy. A single-center tertiary-care hospital. One hundred twenty-six survivors of a critical illness. Confusion Assessment Method for the ICU, Katz activities of daily living, Functional Activities Questionnaire (measuring instrumental activities of daily living), Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score, and Awareness Questionnaire were used. Associations between delirium duration and outcomes were determined via proportional odds logistic regression with generalized estimating equations (for Katz activities of daily living and Functional Activities Questionnaire scores) or via generalized least squares regression (for Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score and Awareness Questionnaire scores). Excluding patients who died prior to follow-up but including those who withdrew or were lost to follow-up, we assessed 80 of 99 patients (81%) at 3 months and 63 of 87 patients (72%) at 12 months. After adjusting for covariates, delirium duration was associated with worse activities of daily living scores (p = 0.002) over the course of the 12-month study period but was not associated with worse instrumental activities of daily living scores (p = 0.15) or worse Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score (p = 0.58). Duration of delirium was also associated with lower Awareness Questionnaire Motor/Sensory Factors scores (p 0.02). In the setting of critical illness, longer delirium duration is independently associated with increased odds of disability in activities of daily living and worse motor-sensory function in the following year. These data point to a need for further study into the determinants of functional outcomes in ICU survivors.

You've Come a Long Way, Baby: Or Have You?

Long-Term Prognosis in Children with Neonatal Seizures: A Population-Based Study. Ronen GM, Buckley D, Penney S, Streiner DL. Neurology 2007;69(19): 1816–1822. OBJECTIVE: To examine outcome and explore for prognostic markers in a cohort &lt;10 years following neonatal seizures. METHODS: We prospectively diagnosed clinical neonatal seizures with high specificity for true epileptic seizures in a population-based setting of all live newborns in the province of Newfoundland, Canada, between 1990 and 1995. Children with neonatal seizures were followed by specialized provincial health services. Follow-up data were collected on epilepsy, physical and cognitive impairments, and other heath issues. RESULTS: Data were available on 82 out of 90 subjects. We added information on six others whose outcome was clearly predictable from earlier information. Prognosis was better for term than for preterm infants ( p = 0.003): term: 28 (45%) normal, 10 (16%) deaths, and 24 (39%) with impairments; preterm: 3 (12%) normal, 11 (42%) deaths, and 12 (46%) with impairments. Of survivors, 17 (27%) developed epilepsy, 16 (25%) had cerebral palsy, 13 (20%) had mental retardation, and 17 (27%) had learning disorders. Variables associated with poor prognosis were Sarnat stage III or equivalent severe encephalopathy, cerebral dysgenesis, complicated intraventricular hemorrhage, infections in the preterm infants, abnormal neonatal EEGs, and the need for multiple drugs to treat the neonatal seizures. Pure clonic seizures without facial involvement in term infants suggested favorable outcome, whereas generalized myoclonic seizures in preterm infants were associated with mortality. CONCLUSIONS: Poor prognosis for premature infants with seizures is reflected in high rates of subsequent long-term disability and mortality. The severity and timing of the pathologic process continue to be the major determinants for outcome.Gestational Age, Birth Weight, Intrauterine Growth, and the Risk of Epilepsy. Sun Y, Vestergaard M, Pedersen CB, Christensen J, Basso O, Olsen J. Am J Epidemiol 2008;167(3):262–270. The authors evaluated the association between gestational age, birth weight, intrauterine growth, and epilepsy in a population-based cohort of 1.4 million singletons born in Denmark (1979-2002). A total of 14,334 inpatients (1979-2002) and outpatients (1995-2002) with epilepsy were registered in the Danish National Hospital Register. Children who were potentially growth restricted were identified through two methods: 1) sex-, birth-order-, and gestational-age-specific z score of birth weight; and 2) deviation from the expected birth weight estimated based on the birth weight of an older sibling. The incidence rates of epilepsy increased consistently with decreasing gestational age and birth weight. The incidence rate ratios of epilepsy in the first year of life were more than fivefold among children born at 22–32 weeks compared with 39–41 weeks and among children whose birth weight was &lt;2,000 g compared with 3,000–3,999 g. The association was modified by age but remained into early adulthood. Incidence rate ratios of epilepsy were increased among children identified as growth restricted according to either of the two methods. In conclusion, short gestational age, low birth weight, and intrauterine growth restriction are associated with an increased risk of epilepsy.

Long-term prognosis in children with neonatal seizures

To examine outcome and explore for prognostic markers in a cohort <10 years following neonatal seizures. We prospectively diagnosed clinical neonatal seizures with high specificity for true epileptic seizures in a population-based setting of all live newborns in the province of Newfoundland, Canada, between 1990 and 1995. Children with neonatal seizures were followed by specialized provincial health services. Follow-up data were collected on epilepsy, physical and cognitive impairments, and other heath issues. Data were available on 82 out of 90 subjects. We added information on six others whose outcome was clearly predictable from earlier information. Prognosis was better for term than for preterm infants (p = 0.003): term: 28 (45%) normal, 10 (16%) deaths, and 24 (39%) with impairments; preterm: 3 (12%) normal, 11 (42%) deaths, and 12 (46%) with impairments. Of survivors, 17 (27%) developed epilepsy, 16 (25%) had cerebral palsy, 13 (20%) had mental retardation, and 17 (27%) had learning disorders. Variables associated with poor prognosis were Sarnat stage III or equivalent severe encephalopathy, cerebral dysgenesis, complicated intraventricular hemorrhage, infections in the preterm infants, abnormal neonatal EEGs, and the need for multiple drugs to treat the neonatal seizures. Pure clonic seizures without facial involvement in term infants suggested favorable outcome, whereas generalized myoclonic seizures in preterm infants were associated with mortality. Poor prognosis for premature infants with seizures is reflected in high rates of subsequent long-term disability and mortality. The severity and timing of the pathologic process continue to be the major determinants for outcome.