Deborah L. Snell

Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability

Post-concussion syndrome (PCS) can affect up to 20%-30% of patients with mild closed head injury (mCHI), comprising incomplete recovery and debilitating persistence of post-concussional symptoms. Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI. Here, we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery. We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS. We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (i.e. mCHI patients of similar injury severity but good recovery) on reflexive, anti- and self-paced saccades, memory-guided sequences and smooth pursuit. All completed neuropsychological testing and health status questionnaires. Mean time post-injury was 140 days in the PCS group and 163 days in the control group. The PCS group performed worse on anti-saccades, self-paced saccades, memory-guided sequences and smooth pursuit, suggesting problems in response inhibition, short-term spatial memory, motor-sequence programming, visuospatial processing and visual attention. This poorer oculomotor performance included several measures beyond conscious control, indicating that subcortical functionality in the PCS group was poorer than expected after mCHI. The PCS group had poorer neuropsychological function (memory, complex attention and executive function). Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability. Compared with neuropsychological tests, eye movements were more likely to be markedly impaired in PCS cases with high symptom load. Poorer eye movement function, and particularly poorer subcortical oculomotor function, correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health. Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment. Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment, eye movements showed additional dysfunction in motor/visuospatial areas, response inhibition, visual attention and subcortical function. Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity, but also has a biological substrate. Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile. Routine oculomotor testing should be feasible in centres with existing access to this technology.

A systematic review of psychological treatments for mild traumatic brain injury: An update on the evidence

Mild traumatic brain injury (MTBI) is common and results in persisting disability for a minority of cases. Evidence guiding clinical management of this more complex group is lacking. This study systematically reviews psychological/neuropsychological treatments for adults with MTBI, with an emphasis on external validity. A total of 8 further studies were found adding to 10 from previous reviews. Although the methodological quality remains poor, mild supportive evidence was found for educational interventions provided early following injury. However, the routine provision of interventions for all MTBI cases may not be effective. Continuing and novel research efforts are needed to identify factors associated with poor outcomes to enable efficient targeting of healthcare resources.

Associations between illness perceptions, coping styles and outcome after mild traumatic brain injury: Preliminary results from a cohort study

Purpose: The objective of this study was to examine associations between injury perceptions, coping, distress and outcome after mild traumatic brain injury (MTBI). Design: A prospective observational study with repeated measures. This study reports results from the first of two study visits. Participants: Participants (n = 147) were recruited within 3 months following presentation to a concussion clinic or an emergency department setting. Methods: Clinical and demographic information was collected and participants completed a range of questionnaires (Revised Illness Perceptions Questionnaire, Brief COPE, Rivermead Post-Concussion Symptoms Questionnaire, Rivermead Follow-Up Questionnaire and HADS). Associations between independent variables and outcome were examined using odds ratios and 95% confidence intervals. Results: Preliminary results suggested participants endorsing stronger beliefs about the injury identity (p < 0.05) and emotional impact (p < 0.01) had significantly greater odds of poor outcome at 3 months. There were also associations between higher educational attainment (p < 0.05), using active coping strategies (p < 0.06) and poor outcome. Conclusions: These variables appeared important determinants of outcome early after MTBI and may help identify those at risk for slow recovery. Current reassurance-based interventions may be improved by targeting such variables.

An analysis of consumer perspectives following contact with an eating-disorders service

Objective: The views of consumers following contact with treatment for eating disorders represent an underresearched aspect of service provision. The aim of this paper is to examine patterns of consumer satisfaction following contact with a specialist eatingdisorders service. Method: Using both a structured and an open-ended questionnaire format, consumer perspectives were sought routinely through postal survey 3 months after the point of first contact. Responses were analysed from 120 patients who returned their questionnaires during the 2-year period ending in December 1998. Results: Although the structured response format indicated high rates of satisfaction, the open-ended format revealed five categories describing the perceived best and worst aspects following consultation with the service. The category of therapeutic alliance drew the majority of positive comments, while the most frequently cited worst aspect of consultation was the category of treatment type. Conclusions: People with eating disorders form a unique group of mental health consumers to survey for satisfaction. While approval ratings prompted by both structured and open-ended questions were high, and centred around the theme of therapeutic alliance, the most frequent source of negative commentary was activities and structures considered essential by traditional treatment modalities. This provides important insights into the predicaments of people with eating disorders presenting for treatment, and the importance of developing satisfaction surveys to accommodate such predicaments and concerns.

Examination of outcome after mild traumatic brain injury: The contribution of injury beliefs and Leventhal's Common Sense Model

Associations between components of Leventhals common sense model of health behaviour (injury beliefs, coping, distress) and outcome after mild traumatic brain injury (MTBI) were examined. Participants (n = 147) were recruited within three months following MTBI and assessed six months later, completing study questionnaires at both visits (Illness Perceptions Questionnaire Revised, Brief COPE, Hospital Anxiety and Depression Scale). Outcome measures included the Rivermead Post-Concussion Symptoms Questionnaire and Rivermead Head Injury Follow-Up Questionnaire. Univariate and multivariate (logistic regression) analyses examined associations between injury beliefs, coping and distress at baseline, and later outcome. Participants endorsing stronger injury identity beliefs (p < .01), expectations of lasting severe consequences (p < .01), and distress (p < .01) at time one, had greater odds of poor outcome at time two. Coping styles were also associated with later outcome although variability in findings limited interpretability. Associations between psychological variables and outcome were examined and 76.5% of cases were correctly classified by the model. Consistent with Leventhals model, participant beliefs about their injury and recovery had significant associations with outcome over time. Coping also appeared to have important associations with outcome but more research is required to examine these. Current reassurance-based interventions may be improved by targeting variables such as injury beliefs, coping and adjustment soon after injury.

Factor Structure of the Brief COPE in People With Mild Traumatic Brain Injury

Objective:To investigate the factor structure and internal consistency of the Brief COPE, adapted for use with adults with mild traumatic brain injury (MTBI). Design:Prospective cohort study. Setting:Hospital based emergency department and concussion clinic. Participants:A total of 147 adults meeting diagnostic criteria for MTBI. Main Measure:Brief COPE. Analyses:The previously reported 9-factor structure of the Brief COPE was tested by using confirmatory factor analysis (CFA) and then exploratory factor analysis (EFA). The Cronbach &agr; was computed for both the original subscales and those derived from EFA. Results:The CFA provided a less than satisfactory fit for the 9-factor model. While the EFA solution was very similar to that of the original scale, the reliability of some derived subscales was low. Further analyses identified improved internal consistency with a 3-factor model reflecting approach, avoidance, and help-seeking coping styles. Conclusions:The Brief COPE has satisfactory psychometric properties for use in MTBI but may be more reliably and meaningfully interpreted using 3 dimensions/subscales rather than 9.

An examination of the factor structure of the Revised Illness Perception Questionnaire modified for adults with mild traumatic brain injury

Objective: Factors influencing outcome after mild traumatic brain injury (MTBI) remain poorly understood. In other health conditions patient illness perceptions have been associated with outcome and have provided targets for effective interventions. These have not been systematically explored in MTBI and identifying reliable and valid measures of illness perceptions in MTBI is a first step before such concepts can be explored in clinical and research settings. Method: This study investigated the factor structure and internal consistency reliability of the Illness Perceptions Questionnaire-Revised (IPQ-R) modified for MTBI in a sample of 147 adults recruited within 3 months of injury. Results: The results demonstrated a close replication of the original factor structure although there were notable exceptions likely to be specific to MTBI and potentially other acutely injured populations. Final scales showed good internal consistency although factors relating to causal attribution were less so. Conclusion: The IPQ-R (MTBI) provides an acceptable measure of key components of injury perceptions after MTBI. Minor refinements appear required if this measure is to make a contribution to research and clinical practice in injury-based populations such as MTBI.

The five-year radiological results of the uncemented Oxford medial compartment knee arthroplasty

This study reports on the first 150 consecutive Oxford cementless unicompartmental knee arthroplasties (UKA) performed in an independent centre (126 patients). All eligible patients had functional scores (Oxford knee score and high activity arthroplasty score) recorded pre-operatively and at two- and five-years of follow-up. Fluoroscopically aligned radiographs were taken at five years and analysed for any evidence of radiolucent lines (RLLs), subsidence or loosening. The mean age of the cohort was 63.6 years (39 to 86) with 81 (53.1%) males. Excellent functional scores were maintained at five years and there were no progressive RLLs demonstrated on radiographs. Two patients underwent revision to a total knee arthroplasty giving a revision rate of 0.23/100 (95% confidence interval 0.03 to 0.84) component years with overall component survivorship of 98.7% at five years. There were a further four patients who underwent further surgery on the same knee, two underwent bearing exchanges for dislocation and two underwent lateral UKAs for disease progression. This was a marked improvement from other UKAs reported in New Zealand Joint Registry data and supports the designing centres early results.

The contribution of psychological factors to recovery after mild traumatic brain injury: is cluster analysis a useful approach?

Abstract Objectives: Outcomes after mild traumatic brain injury (MTBI) vary, with slow or incomplete recovery for a significant minority. This study examines whether groups of cases with shared psychological factors but with different injury outcomes could be identified using cluster analysis. Method: This is a prospective observational study following 147 adults presenting to a hospital-based emergency department or concussion services in Christchurch, New Zealand. This study examined associations between baseline demographic, clinical, psychological variables (distress, injury beliefs and symptom burden) and outcome 6 months later. A two-step approach to cluster analysis was applied (Ward’s method to identify clusters, K-means to refine results). Results: Three meaningful clusters emerged (high-adapters, medium-adapters, low-adapters). Baseline cluster-group membership was significantly associated with outcomes over time. High-adapters appeared recovered by 6-weeks and medium-adapters revealed improvements by 6-months. The low-adapters continued to endorse many symptoms, negative recovery expectations and distress, being significantly at risk for poor outcome more than 6-months after injury (OR (good outcome) = 0.12; CI = 0.03–0.53; p < 0.01). Conclusions: Cluster analysis supported the notion that groups could be identified early post-injury based on psychological factors, with group membership associated with differing outcomes over time. Implications for clinical care providers regarding therapy targets and cases that may benefit from different intensities of intervention are discussed.

Attending to biographical disruption: the experience of rehabilitation following tetraplegia due to spinal cord injury

Abstract Purpose: To explore the experience of rehabilitation from the perspective of individuals with tetraplegia. Methods: Semi-structured interviews of between 40 and 60 min were conducted with three men and one woman, with spinal injuries at C7 or higher, within 6 months of discharge from inpatient spinal cord injury (SCI) rehabilitation. Data were subject to an Interpretive Phenomenological Analysis (IPA). Results: Participants described their injuries as more than a biological impairment that limited certain functional abilities. For them, SCI was a sudden event that also disrupted one’s “life biography”. Interviews uncovered three key themes essential to an individual’s ability to restore feelings of self-agency and biographical continuity: The importance of information, regaining control, and restoring a sense of personal narrative. Conclusion: Findings from studies using IPA have much to contribute to discussion and debate at the level of rehabilitation theory and can guide future research directions. The findings of the present study support a growing body of literature that argues that rehabilitation research needs to focus more intensely on the biographical disruption caused by SCI. Implications for Rehabilitation Participants in the present study experienced a significant disruption to their biographical narratives following a SCI as they entered an unknown and uncertain world. The findings from the present study provide an evidence-base that is best applied to discussion regarding psychosocial adjustment at the level rehabilitation theory. The concepts of identity and biographical disruption are appearing more frequently in qualitative literature and both merit further investigation to assess their prevalence among the wider SCI populations.