Bonnie Swaine

Recommendations for the Use of Common Outcome Measures in Pediatric Traumatic Brain Injury Research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroups recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum

Primary objective: To investigate the experiences of individuals who had sustained a traumatic brain injury, their families and the physicians and health professionals involved, from the critical care episodes and subsequent rehabilitation. Research design: Semi-structured interviews were conducted with individuals who had sustained a TBI (n = 8) and their families (n = 8) as well as with the health professionals (or service providers) (n = 22) and physicians (n = 9) who provided them care. Main outcomes and results: Results revealed the difficulties encountered by the different people involved, from the standpoint of the readjustment of the individual with the TBI and their family, the relationships among the various actors and the continuity of care. Conclusions: This study brings to light the importance of including the family and the person with a TBI in the care process by calling for their participation and by setting up suitable structures that prioritize a meaningful partnership among the key individuals.

Quality of Life of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up

OBJECTIVE To describe and compare the quality of life (QOL) of persons with lower-limb amputation (LLA) at admission (T1), discharge (T2), and 3 months after rehabilitation discharge (T3) and to explore the relationships between QOL and demographic and clinical variables including body image. DESIGN Longitudinal case series. SETTING Inpatient rehabilitation facility. PARTICIPANTS Consecutive sample of 19 unilateral persons with LLA (14 men, mean age, 53.4+/-14.6y). INTERVENTION Interdisciplinary rehabilitation. MAIN OUTCOME MEASURES Generic and specific QOL measures and perception of body image at T1, T2, and T3. RESULTS Subjective QOL was relatively high at T1, T2, and T3 (0.87/2, 1.1/2, and 1.0/2, respectively) except for items related to physical functioning. There was no significant change over time for all but 1 QOL satisfaction measure (ability to go outside, P=.024). Prosthesis-related QOL was high at discharge and follow-up. Body-image disturbances were absent over the study period. QOL satisfaction and prosthesis satisfaction were strongly related to lower-limb pain and psychosocial factors (eg, body image). CONCLUSIONS QOL of persons with LLA was high and remained relatively stable during inpatient rehabilitation and 3 months after discharge.

Hospitalizations and emergency department visits for TBI in Ontario.

OBJECTIVE The aim of this study was to determine the number of annual hospitalizations and overall episodes of care that involve a traumatic brain injury (TBI) by age and gender in the province of Ontario. To provide a more accurate assessment of the prevalence of TBI, episodes of care included visits to the emergency department (ED), as well as admissions to hospital. Mechanisms of injury for overall episodes were also investigated. METHODS Traumatic brain injury cases from fiscal years 2002/03-2006/07 were identified by means of ICD-10 codes. Data were collected from the National Ambulatory Care Reporting System and the Discharge Abstract Database. RESULTS The rate of hospitalization was highest for elderly persons over 75 years-of-age. Males generally had higher rates for both hospitalizations and episodes of care than did females. The inclusion of ED visits to hospitalizations had the greatest impact on the rates of TBI in the youngest age groups. Episodes of care for TBI were greatest in youth under the age of 14 and elderly over the age of 85. Falls (41.6%) and being struck by or against an object (31.1%) were the most frequent causes for a TBI. CONCLUSIONS The study provides estimates for TBI from the only Canadian province that has systematically captured ED visits in a national registry. It shows the importance of tracking ED visits, in addition to hospitalizations, to capture the burden of TBI on the health care system. Prevention strategies should include information on ED visits, particularly for those at younger ages.

Residual Effects of a Traumatic Brain Injury on Locomotor Capacity: A First Study of Spatiotemporal Patterns During Unobstructed and Obstructed Walking

Objectives:To understand the residual locomotor effects of a traumatic brain injury (TBI) on unobstructed and obstructed walking. Participants:Eight young, high-functioning adults with TBI and 4 healthy subjects. Main outcome measures:Spatiotemporal gait parameters and their relation to specific clinical measures of severity and locomotor and balance abilities. Results:Subjects with TBI walked slower and showed a tendency for greater foot clearances in all conditions. Slower walking was due to decreased stride lengths and not cadence, while higher foot clearances were due to placing the trailing foot farther from the obstacle and increasing hip flexion angles during avoidance. Conclusions:The results suggest that this highly functional TBI population used increased caution. Measures of injury severity did not provide simple predictions of locomotor ability, but the one-legged stance test with eyes closed correlated to walking capacity.

Altered integrated locomotor and cognitive function in elite athletes 30 days postconcussion: a preliminary study.

Objective:To begin to understand changes in locomotor navigation in elite athletes following concussion. Methods:Clinical measures and gait analysis were undertaken on average 37.33 days (SD = 4.8) postconcussion for 6 athletes as well as for a control group of athletes matched for age, sex, and team. The locomotor task consisted of walking at a self-selected speed along an unobstructed or obstructed path with and without a visual interference task. The trends for 4 dependent variables were described (2 for gait behavior and 2 for cognitive behavior). A principal component analysis was used to reduce data to root sources of variance among these variables. General group differences were tested with Wilcoxon matched-pairs tests on factorial scores. Results:Athletes with concussion were symptom free at the time of testing and their neuropsychological test results were not different from those of athletes in the control group. However, when the laboratory data between paired groups were compared, descriptive analyses suggested potential group differences in navigating the obstacle. The simultaneous Stroop task appeared to present difficulty for both groups. A significant group effect was found on the component of the factorial analysis that was highly loaded with both gait and cognitive variables (minimum clearance, Stroop task errors, and cognitive dual-task costs), generally supporting the descriptive analyses by suggesting that athletes with concussion do not navigate the targeted complex environments like the control group. Conclusions:Athletes with concussion appear to still show navigational deficits in environments well after being considered fully recovered according to current return-to-play protocols. Although still preliminary and requiring further study, the present findings suggest that functional assessment within complex environment contexts could be considered before sending athletes back to play following a concussion, even in the absence of postconcussion symptoms or with normal clinical outcomes.

Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study.

OBJECTIVE. The objective of this study was to determine whether children who sought care for a head injury were at greater risk of having a subsequent head injury within the following 6 and 12 months compared with children who sought care for an injury other than to the head. DESIGN/SETTING. This was a longitudinal cohort study conducted in the emergency departments of 2 Montreal (Quebec, Canada) pediatric hospitals. PARTICIPANTS. The parents of 11867 injured children aged 1 to 18 years were interviewed by telephone at 6 (n = 10315) and 12 (n = 9486) months after their childs injury to ascertain outcome (ie, subsequent head injury) and to provide information on potential risk factors (age, gender, chronic medical condition, activity level, and socioeconomic status). MAIN OUTCOME MEASURE. The outcome of interest was a head injury requiring medical attention within the following year ascertained by parental recall or physician claims data. RESULTS. A total of 245 and 386 previously head-injured children sustained a subsequent head injury within 6 and 12 months, respectively. Children who sought care for an initial head injury (n = 3599) were at higher risk of having a subsequent head injury within 6 months than children who sought care for an injury not to the head (n = 6716). The adjusted odds ratio suggested weak confounding by age, gender, and history of previous head injury. Results were consistent on the basis of physician claims data and 12-month follow-up interview data. CONCLUSIONS. These results provide evidence that having a head injury increases a childs risk of having a subsequent head injury. Although age, gender, and history of previous head injury confound the relationship, the effect remains substantial.

Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury.

ObjectiveTo evaluate childrens self-efficacy related to their practice of physical activities prior to and after a mild traumatic brain injury (mTBI), and compare these to those of noninjured children matched for age, sex, and premorbid level of physical activity. Participants and MethodsThirty-four children (mean age: 12 ± 3 years) in each group. Children with mTBI were assessed 1 day postinjury (to document preinjury status) and at 12 weeks post-mTBI using a self-efficacy questionnaire, the Physical Activity Questionnaire, the Athletic Competence subscale of the Self-Perception Profile for Children or Adolescents, and the Rivermead Post-Concussion Symptoms Questionnaire. Noninjured children underwent the same assessments at a corresponding time interval. ResultsAt 12 weeks postinjury, self-efficacy scores of children with mTBI were significantly lower than initial (ie, pretraumatic) values and those of noninjured children. The children with mTBI had, however, returned to their preinjury level of participation in physical activities and maintained their athletic competence. ConclusionsAfter mTBI, children appear to lack confidence in their ability to perform during physical activities as compared to before their injury. Intervention strategies such as information or counseling sessions targeting children and their parents may minimize the impact of the mTBI on childrens confidence in their performance in physical activities.

Alterations to locomotor navigation in a complex environment at 7 and 30 days following a concussion in an elite athlete

Primary objective: To compare the locomotor capacity during (1) unobstructed walking and (2) the circumvention of fixed obstacles with and without a simultaneous visual task in an elite athlete before and after a sports-related concussion. Research design: Case report. Methods and procedures: Gait analysis and clinical neuropsychological measures were taken pre- and at 7 and 30 days post-injury in an 18 year old male junior hockey player. The task consisted of walking along an unobstructed or obstructed path with or without a visual interference task. Measurements included dual tasks costs, response errors, maximal gait speed and minimal clearance with the obstacle. Main outcome and results: Although the athlete was symptom-free and neuropsychological test results returned to baseline relatively quickly, he showed continued errors in the interference task, abnormally small obstacle clearance distances and decreased maximal gait speed up to 30 days after the concussion. Conclusions: Concussion can result in persistent planning and attention deficits in ecologically valid, complex environments. This report suggests that functional assessment within an ecological context could be an innovative way to evaluate concussed athletes before sending them back to play, even in the absence of medically related symptoms or abnormal neuropsychological test results.

Can measures of cognitive function predict locomotor behaviour in complex environments following a traumatic brain injury

Primary objective: To determine the relationships between clinical measures of executive function and attention, and laboratory measures of anticipatory locomotor adaptations with dual tasks following a TBI. Methods and procedures: Ten people with moderate or severe TBI were compared to 10 healthy subjects for neuropsychological measures in the clinic, as well as locomotor patterns and reading time in the laboratory for adapted Stroop tasks (Bar and Word) during unobstructed and obstructed walking. Main outcomes and results: As previously found 1 (Vallee M, McFadyen BJ, Swaine B, Doyon J, Cantin JF, Dumas D. Effects of environmental demands on locomotion after traumatic brain injury. Archives of Physical Medicine Rehabilitation 2006;87:806--813) during the locomotor activities, subjects with TBI walked slower, had higher clearance margins and took longer to read during the Stroop tasks than healthy subjects. In general, subjects with TBI also showed deficits in executive functions and attention. Significant relationships were specifically observed between scores on Trail Making B and clearance margins for subjects with TBI, but not for healthy subjects. Alternatively, significant relationships between clinical scores on Stroop and dual task Stroop reading times were obtained for healthy subjects but not for subjects with TBI. Conclusions: These results suggest that measures of executive functioning and attention may be associated to locomotor behaviour in complex environments following a moderate to severe TBI.