Elaine de Guise

Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury

Primary objective: To compare functional physical and cognitive outcome of patients in three age groups with mild, moderate and severe traumatic brain injury (TBI) at discharge from acute care. Research design: Retrospective database review. Methods and procedures: Scores on the Extended Glasgow Outcome Scale (GOSE) and on the FIM™ instrument,discharge destination and length-of-stay (LOS) were gathered and compared for 2327 patients with TBI admitted to a level 1 trauma hospital from 1997–2003 divided into three age groups; 971 patients between 18–39 years, 672 between 40–59 years and 684 aged 60–99 years. Main outcomes and results: Relative to younger adults with similar TBI severity, elderly patients showed worse outcome on the GOSE and FIM™ instrument (physical and cognitive ratings) and longer LOS. No difference was observed between the young and middle-aged groups except for cognitive FIM™ ratings and LOS for severe TBI. A higher percentage of elderly patients went to in-patient rehabilitation, to long-term care facilities or died compared to young and middle-aged patients. A higher number of young and middle-aged patients were discharged home. Conclusions: Further development of services in early rehabilitation as well as post-rehabilitation geared to the specific needs of the elderly patient with TBI is required as the population ages.

Electrophysiology and Functional MRI in Post-Acute Mild Traumatic Brain Injury

Symptoms persisting beyond the acute phase (>2 months) after a mild traumatic brain injury (MTBI) are often reported, but their origin remains controversial. Some investigators evoke dysfunctional cerebral mechanisms, while others ascribe them to the psychological consequences of the injury. We address this controversy by exploring possible cerebral dysfunction with functional magnetic resonance imaging (fMRI) and event-related potentials (ERP) in a group of patients during the post-acute phase. Fourteen MTBI symptomatic patients (5.7±2.9 months post-injury) were tested with fMRI and ERP using a visual externally ordered working memory task, and were compared with 23 control subjects. Attenuated blood oxygen level dependent (BOLD) signal changes in the left and right mid-dorsolateral prefrontal cortex (mid-DLPFC), the putamen, the body of the caudate nucleus, and the right thalamus were found in the MTBI group compared with the control group. Moreover, symptom severity and BOLD signal changes were correlated: patients with more severe symptoms had lower BOLD signal changes in the right mid-DLPFC. For ERP, a group×task interaction was observed for N350 amplitude. A larger amplitude for the working memory task than for the control task was found in control subjects, but not in MTBI subjects, who had weak amplitudes for both tasks. This study confirms that persistent symptoms after MTBI cannot be uniquely explained by psychological factors, such as depression and/or malingering, and indicates that they can be associated with cerebral dysfunction. ERP reveals decreased amplitude of the N350 component, while fMRI demonstrates that the more severe the symptoms, the lower the BOLD signal changes in the mid-DLPFC.

Comprehensive Clinical Picture of Patients with Complicated vs Uncomplicated Mild Traumatic Brain Injury

To compare the acute clinical profile of patients with uncomplicated vs complicated mild TBI (MTBI), socio-demographic and medical history variables were gathered for 176 patients diagnosed with MTBI and with (complicated, N = 45) or without (uncomplicated, N = 131) positive findings on cerebral imaging. Neurological examination, neuropsychological assessment and self-evaluation of post-concussive symptoms were done at 2 weeks post trauma. Patients with complicated MTBI were more likely to show auditory and vestibular system dysfunction. Surprisingly, the uncomplicated group reported more severe post-concussive symptoms than patients with positive CT scans. The groups showed no other difference in neurological, psychological, or cognitive outcome. A complete neurological examination should be done acutely in patients with MTBI to determine more specific follow-up required.

Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of injury

Primary objective: To investigate the relationship between pre-injury alcohol abuse and intoxication at time of injury on duration of post-traumatic amnesia (PTA) as well as on early functional and neurobehavioural outcomes in persons with traumatic brain injury (TBI) hospitalized in an acute care setting. Methods and procedure: Sixty persons with mild, moderate and severe TBI admitted to the intensive care unit were part of this retrospective study. Main outcomes: Duration of PTA, length of stay (LOS), Extended Glasgow Outcome Scale (GOS-E) score, the FIM™ score as well as early neuropsychological outcome measured by the Neurobehavioural Rating Scale Revised (NBRS-R). Results: 2-factor ANOVAs and chi-squares tests showed that PTA and LOS were significantly longer in the group of patients with pre-injury alcohol abuse, regardless of whether they were intoxicated or not at the time of injury. Moreover, the FIM™ total and cognitive scores were significantly higher for the group intoxicated on admission compared to the sober group. However, GOS-E scores and results on the NBRS-R were similar. Conclusions: Despite a longer PTA and LOS, global and neurobehavioural outcomes at discharge from acute care were not different for those with pre-injury alcohol abuse.

Early prediction of language impairment following traumatic brain injury

Primary objective: This study investigated which factors collected early in the acute care setting (age, education, cerebral imaging, Glasgow Coma Scale score) would predict initial impairments of language comprehension and expression in patients with traumatic brain injury (TBI) of all severity. Methods and procedures: Results of language tests carried out during the patients’ stay in an acute tertiary trauma centre were obtained. These tests measured performance in the areas of confrontation naming, auditory comprehension, semantic and letter category naming and comprehension of verbal absurdities. Data for the predictive variables were gathered by retrospective chart review. Stepwise multiple linear regressions were carried out on the predictive variables. Main outcomes and results: Education and TBI severity as measured with the GCS score were the most significant factors predicting language deficits in the acute care setting. Conclusions: These findings will serve to guide health care professionals in predicting prognosis for cognitive-communication deficits post-TBI and in planning for appropriate resources in speech-language pathology to meet these patients’ needs.

Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury

Primary objective: This study assesses the influence of socio-demographic, psychosocial, clinical and radiological variables on the outcome of patients with mild traumatic brain injury (MTBI) in an acute care inpatient setting. Research design: Retrospective cohort study. Methods and procedure: A total of 2127 inpatients with MTBI were included. Outcomes measured were Extended Glasgow Outcome Scale (GOS-E), the FIM® instrument, length of stay (LOS) and discharge destination. Main outcomes and results: Fifty-four per cent of patients with MTBI with a median GOS-E of 2 were discharged home with no need for further follow-up. Age, LOS, lower Glasgow score (GCS) at admission, insurance coverage and positive CT scans were associated with rehabilitation referrals on discharge. Age, LOS, alcohol and drug abuse, motor vehicle collision and lower GCS at admission were associated with greater physical disabilities and functional impairment at discharge. FIM® cognitive functional scores were higher in women, younger patients and patients without psychiatric disorders. Brain lesions were correlated with longer LOS. CT scan findings in patients with MTBI may help clinicians predict the final outcome and resources required for patient care during their hospitalization and on discharge. Conclusion: This study can help healthcare professionals in treating and planning future care of patients with MTBI.

The influence of pain on cerebral functioning after mild traumatic brain injury.

More than 75% of patients with mild traumatic brain injury (MTBI) report chronic pain whose potential detrimental effects on cognitive recovery need to be identified. The objective of this study was to investigate the relationship between pain, performance on a working memory task, gray matter density, and mid-dorsolateral prefrontal cortex (mid-DLPFC) activation in subjects with a MTBI. For comparison purposes, we performed identical correlation analyses with a group of subjects without MTBI who sustained sports injuries. Twenty-four subjects who experienced a MTBI in the past 12 months, 16 control subjects, and 29 subjects with sport injuries were included. One hour prior to entering the magnetic resonance scanner, the subjects were asked to fill out the pain Visual Analogue Scale. Subsequently, a high-resolution T1-weighted image was acquired followed by a functional magnetic resonance imaging session using the visual externally ordered working memory task. Results showed that MTBI subjects reporting severe pain in the hour preceding the testing had reduced mid-DLPFC activation during the working memory task and poorer performance on the task. Subjects with sport injuries and severe levels of pain showed the reverse pattern: pain was associated with higher activation in the mid-DLPFC and did not correlate with performance. Gray matter density measures were independent of pain level. This study showed that behavioral performance and cerebral functioning are affected by pain after a MTBI. Moreover, this study suggests that pain, cognition, and cerebral functioning interactions could not easily be generalized from one clinical population to another.

Acute evaluation of conversational discourse skills in traumatic brain injury

Abstract This study looked at performance on the conversational discourse checklist of the Protocole Montréal d’évaluation de la communication (D-MEC) in 195 adults with TBI of all severity hospitalized in a Level 1 Trauma Centre. To explore validity, results were compared to findings on tests of memory, mental flexibility, confrontation naming, semantic and letter category naming, verbal reasoning, and to scores on the Montreal Cognitive Assessment. The relationship to outcome as measured with the Disability Rating Scale (DRS), the Extended Glasgow Outcome Scale (GOS-E), length of stay, and discharge destinations was also determined. Patients with severe TBI performed significantly worse than mild and moderate groups (χ2KW2df = 24.435, p = .0001). The total D-MEC score correlated significantly with all cognitive and language measures (p < .05). It also had a significant moderate correlation with the DRS total score (r = −.6090, p < .0001) and the GOS-E score (r = .539, p < .0001), indicating that better performance on conversational discourse was associated with a lower disability rating and better global outcome. Finally, the total D-MEC score was significantly different between the discharge destination groups (F(3,90) = 20.19, p < .0001). Thus, early identification of conversational discourse impairment in acute care post-TBI was possible with the D-MEC and could allow for early intervention in speech-language pathology.

Early conversational discourse abilities following traumatic brain injury: An acute predictive study

Abstract Primary objective: To date, little information is available regarding communication and conversational discourse proficiency post-traumatic brain injury (TBI) in the acute care phase. The main goal of this study was to examine how conversational discourse impairment following TBI predicts early outcome. Factors which influence conversational discourse performance were also explored. Methods: The conversational discourse checklist of the Protocole Montréal d’évaluation de la communication (D-MEC) was administered in an acute tertiary care trauma centre to 195 adults within 3 weeks post-TBI. Outcome was measured with the Disability Rating Scale (DRS), the extended Glasgow Outcome Scale (GOS-E) and included discharge destinations from acute care. Main outcomes and results: Linear regression results showed that the D-MEC total score, age and initial GCS score accounted for 50% of the variation of the DRS scores. The DRS score was lower, signifying better outcome, when the total D-MEC score was higher, the subject was younger and when the initial GCS score was higher. Moreover, D-MEC performance significantly predicted the moderate and severe disability categories of the GOS-E and the probability of requiring rehabilitation (p < 0.05). Conclusion: These results provide additional information to guide healthcare professionals in predicting overall outcome acutely post-TBI.

The Montreal Cognitive Assessment in Persons with Traumatic Brain Injury

The objective of this study was to examine the performance of patients with traumatic brain injury (TBI) on the Montreal Cognitive Assessment (MoCA). The MoCA was administered to 214 patients with TBI during their acute care hospitalization in a Level 1 trauma center. The results showed that patients with severe TBI had lower scores on the MoCA compared with patients with mild and moderate TBI, F(2, 211) = 10.35, p = .0001. This difference was found for visuospatial/executive, attention, and orientation subtests (p < .05). Linear regression demonstrated that age, education, TBI severity, and the presence of neurological antecedents were the best predictors of cognitive impairments explaining 42% of the total variability of the MoCA. This information can enable clinicians to predict early cognitive impairments and plan cognitive rehabilitation earlier in the recovery process.