Audny Anke

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

Objective To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks). Design Multicentre, blinded, randomised controlled trial. Setting Outpatient multidisciplinary back clinics of five Norwegian hospitals. Participants Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity. Interventions Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval. Main outcome measures Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain. Results Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n=40), estimated change in the Oswestry disability index from the adjusted baseline value was −4.7 (95% confidence intervals −0.6 to −8.8) at 6 weeks, −11.4 (−6.3 to −14.5) at 12 weeks, and −14.3 (−10.0 to −18.7) at 52 weeks. For the epidural saline intervention group (n=39) compared with the sham group, differences in primary outcome were −0.5 (−6.3 to 5.4) at 6 weeks, 1.4 (−4.5 to 7.2) at 12 weeks, and −1.9 (−8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were −2.9 (−8.7 to 3.0), 4.0 (−1.9 to 9.9), and 1.9 (−4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Conclusions Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy. Trial registration Current Controlled Trials ISRCTN No 12574253.

Incidence of Hospital-Admitted Severe Traumatic Brain Injury and In-Hospital Fatality in Norway: A National Cohort Study

Aims: The aims of this study were to assess the incidence of hospital-admitted severe traumatic brain injury (TBI) in the adult population in Norway, and to determine whether there were differences in the epidemiological characteristics of severe TBI between rural and urban regions. Methods: A prospective population-based study on adults with severe TBI admitted to the Norwegian Trauma Referral Centres during the 2-year period (2009–2010). The electronic patient register was searched weekly for ICD-10 diagnoses of intracranial injuries (S06.0–S06.9) to identify patients. Severe TBI was defined as lowest unsedated Glasgow Coma Scale Score ≤8 during the first 24 h after injury. Results: The annual age-adjusted incidence was estimated at 5.2/100,000 in 2009 and 4.1/100,000 in 2010. The highest frequency of hospitalized patients was found among the youngest and the oldest age groups. The most common causes of injury were falls and transport accidents. The highest in-hospital case-fatality rate was found among the oldest patients. There were consistent epidemiological characteristics of severe TBI from both rural and urban regions. Conclusions: The incidence of hospital-admitted patients with severe TBI in this national study supports the declining incidence of TBI reported internationally. No major differences were found in epidemiological characteristics between the urban and rural parts of Norway.

ARM uSE IN PATIENTS WITH SuBACuTE STRoKE MoNIToRED BY ACCELERoMETRY: ASSoCIATIoN WITH MoToR IMPAIRMENT AND INFLuENCE oN SELF-DEPENDENCE

OBJECTIVE To assess the effect of arm motor impairment on actual arm use in the early post-stroke period and explore its association with self-care dependency. SUBJECTS Thirty-one patients recruited within the 30 first days after stroke. METHODS Motor impairment of the upper extremity was measured with Fugl-Meyer Motor Assessment (FMA) and arm use was measured with accelerometry. Arm movement ratio (AMR), the ratio of arm use duration between the more and less affected arm, was calculated. Self-care dependency was defined as needing personal assistance in primary self-care activities. RESULTS FMA of the more affected arm was strongly associated with AMR (Spearmans correlation coefficient -0.851, p>0.001), although some patients deviated considerably from the regression line. Covariates did not have any influence on this relation. Both arm motor function and actual arm use related to self-care dependency, but were no longer significant when we controlled for lower extremity motor function. CONCLUSION FMA and AMR correlated highly in the early post-stroke period. These measures relate to different dimensions of the International Classification of Functioning and Health, and could be supplementary measures to reveal non-use of the affected arm. Arm use and arm impairment were not significantly associated with self-care dependency in our sample.

Prediction of on-road driving ability after traumatic brain injury and stroke

The aim of the study was to examine the predictive value of widely used standardized neuropsychological tests in a clinical setting for on‐road driving performance in patients with cerebral stroke or traumatic brain injury (TBI), and to provide cut‐off values for neuropsychological test results under which driving should not be recommended.

A meta-analysis of constraint-induced movement therapy after stroke.

OBJECTIVE To evaluate the effect of constraint-induced movement therapy in adult stroke patients and to examine the impact of time since stroke and various treatment modalities. DATA SOURCES PubMed, EMBASE, Cochrane and PEDro trial registers were searched for clinical trials published before November 2012. STUDY SELECTION Randomized or quasi-randomized controlled trials of constraint-induced movement therapy lasting 2-7 h/day for 8-28 days were included. DATA EXTRACTION Measurements were classified into the following categories: arm motor function, arm motor activity, activities of daily living, and participation. A pooled standardized mean difference (SMD) was calculated for each category. Moderators were: trial quality, behavioural techniques, amount of training, time since stroke, shaping, and the nature of the control group. DATA SYNTHESIS Of 3842 records initially screened 23 trials were included. A small post-treatment effect was found on arm motor function (SMD 0.28, 95% confidence interval (CI) 0.11-0.44). Meanwhile, a moderate effect on arm motor activity was found post-treatment (SMD 0.51, 95% CI 0.30-0.73) and at 3-6 months follow-up (SMD 0.41, 95% CI 0.08-0.74). CONCLUSION Constraint-induced movement therapy can improve arm motor function and improve arm motor activities and may have a lasting effect on arm motor activity.

Health-related Quality of Life 12 months after severe traumatic brain injury: A prospective nationwide cohort study

OBJECTIVE To assess health-related quality of life in individuals with severe traumatic brain injury at 12 months post-injury, applying the Quality of Life after Brain Injury (QOLIBRI) instrument, and to study the relationship between injury-related factors, post-injury functioning and health-related quality of life. DESIGN/SUBJECTS The study is part of a prospective, Norwegian multicentre study of adults (≥ 16 years old) with severe traumatic brain injury, as defined by a Glasgow Coma Scale score of 3-8 during the first 24 h post-injury. A total of 126 patients were included. METHODS Socio-demographic data and injury severity variables were collected. Functioning at 3 and 12 months was assessed with the Glasgow Outcome Scale Extended (GOSE), the Functional Independence Measure (FIM), the Rivermead Post-concussion Questionnaire (RPQ), and the Hospital Anxiety and Depression Scale (HADS). Hierarchical regression analysis was applied. RESULTS Mean QOLIBRI score was 68.5 (standard deviation = 18.8). Predictors of the QOLIBRI in the final regression model were: employment status (p = 0.05), GOSE (p = 0.05), RPQ (p < 0.001) and HADS (p < 0.001). The adjusted R2 showed that the model explained 64.0% of the variance in the QOLIBRI score. CONCLUSION Symptom pressure and global functioning in the sub-acute phase of traumatic brain injury and psychological distress in the post-acute phase are important for health-related quality of life at 12 months post-injury. These domains should be the focus in rehabilitation aiming to improve health-related quality of life in patients with severe traumatic brain injury.

Neuropsychological functioning in a national cohort of severe traumatic brain injury: demographic and acute injury-related predictors

Objectives:To determine the rates of cognitive impairment 1 year after severe traumatic brain injury (TBI) and to examine the influence of demographic, injury severity, rehabilitation, and subacute functional outcomes on cognitive outcomes 1 year after severe TBI. Setting:National multicenter cohort study over 2 years. Participants:Patients (N = 105), aged 16 years or older, with Glasgow Coma Scale score of 3 to 8 and Galveston Orientation and Amnesia Test score of more than 75. Main Measures: Neuropsychological tests representing cognitive domains of Executive Functions, Processing Speed, and Memory. Injury severity included Rotterdam computed tomography score, Glasgow Coma Scale score, and posttraumatic amnesia (PTA) duration, together with length of rehabilitation and Glasgow Outcome Scale–Extended score. Results:In total, 67% of patients with severe TBI had cognitive impairment. Executive Functions, Processing Speed, and Memory were impaired in 41%, 58%, and 57% of patients, respectively. Using multiple regression analysis, Processing Speed was significantly related to PTA duration, Glasgow Outcome Scale–Extended score, and length of inpatient rehabilitation (R2 = 0.30); Memory was significantly related to Glasgow Outcome Scale–Extended score (R2 = 0.15); and Executive Functions to PTA duration (R2 = 0.10). Rotterdam computed tomography and Glasgow Coma Scale scores were not associated with cognitive functioning at 1 year postinjury. Conclusion:Findings highlight cognitive consequences of severe TBI, with nearly two-thirds of patients showing cognitive impairments in at least 1 of 3 cognitive domains. Regarding injury severity predictors, only PTA duration was related to cognitive functioning.

Factors Affecting Caregiver Burden 1 Year After Severe Traumatic Brain Injury: A Prospective Nationwide Multicenter Study.

Objectives:To assess burden in the caregivers of patients with severe traumatic brain injury (TBI) 1 year postinjury, related to caregivers demographic data and social network, patients demographic data, injury severity, and functional status. Design:Prospective national multicenter study. Self-report from caregivers, patient data collected from the national cohort on patients with severe TBI. Participants:92 caregivers. Main outcome measure:The Caregiver Burden Scale (CBS). Results:Total caregiver burden was reported high in 16% of caregivers and moderate in 34%. The mean total burden index was 2.12, indicating a moderate burden. Caregivers reported highest scores on the General strain index, followed by the Disappointment index. Poor social network, feeling loneliness, and caring for patients with severe disability were significant predictors of higher burden in univariate analyses (P < .01). Multiple linear regression analyses showed that experiencing loneliness and caring for a patient with more severe disability were independent predictors for higher caregiver burden for all CBS indices. Marital status (married) and low frequency of meeting friends were significant results in some indices. Conclusions:Lack of a social network, feeling loneliness, and patients functional status are predictors of caregiver burden. General strain, disappointment, and isolation were identified as areas in which caregiver burden is high.

SEVERE TRAUMATIC BRAIN INJURY IN NORWAY: IMPACT OF AGE ON OUTCOME

OBJECTIVE The aim of this study was to investigate the influence of age on mortality and 3-month outcome in a Norwegian cohort of patients with severe traumatic brain injury (TBI). METHODS Norwegian residents ≥ 16 years of age who were admitted with a severe TBI to the countrys 4 major trauma centres in 2009 and 2010 were included, as were adults (16- 64 years) and elderly patients (≥ 65 years). RESULTS Half of the adult subjects and 84% of the elderly subjects were injured by falls. One-third of the adults and half of the elderly subjects were admitted to a local hospital before being transported to a regional trauma hospital. Subdural haematomas were more frequent in the elderly subjects. One-quarter of adults and two-thirds of the elderly subjects died within 3 months. At 3 months, 41% of the adult survivors were still in-patients, mainly in rehabilitation units (92%). Of the surviving elderly subjects, 14% were in-patients and none were in rehabilitation units. There was no difference in functional level for survivors at the 3-month follow-up. CONCLUSION Old age is associated with fall-induced severe TBI and high mortality rates. Less intensive treatment strategies were applied to elderly patients in the present study despite high rates of haemorrhage. Few surviving elderly patients received rehabilitation at 3 months post-injury.

Efficacy of Constraint-Induced Movement Therapy in Early Stroke Rehabilitation A Randomized Controlled Multisite Trial

Background. There is limited evidence for the effects of constraint-induced movement therapy (CIMT) in the early stages of stroke recovery. Objective. To evaluate the effect of a modified CIMT within 4 weeks poststroke. Methods. This single-blinded randomized multisite trial investigated the effects of CIMT in 47 individuals who had experienced a stroke in the preceding 26 days. Patients were allocated to a CIMT or a usual care (control) group. The CIMT program was 3 h/d over 10 consecutive working days, with mitt use on the unaffected arm for up to 90% of waking hours. The follow-up time was 6 months. The primary outcome was the Wolf Motor Function test (WMFT) score. Secondary outcomes were the Fugl-Meyer upper-extremity motor score, Nine-Hole Peg test (NHPT) score, the arm use ratio, and the Stroke Impact Scale. Analyses of covariance with adjustment for baseline values were used to assess differences between the groups. Results. After treatment, the mean timed WMFT score was significantly better in the CIMT group compared with the control group. Moreover, posttreatment dexterity, as tested with the NHPT, was significantly better in the CIMT group, whereas the other test results were similar in both the groups. At the 6-month follow-up, the 2 groups showed no significant difference in arm impairment, function, or use in daily activities. Conclusions. Despite a favorable effect of CIMT on timed movement measures immediately after treatment, significant effects were not found after 6 months.