Ingrid Emanuelson

Epidemiology of traumatic brain injury: a population based study in western Sweden.

Background – This study on traumatic brain injury (TBI) is based on prospective and retrospective population based data from a head injury register in Borås.

Quality of life and post-concussion symptoms in adults after mild traumatic brain injury: a population-based study in western Sweden

Objectives – To study quality of life and subjective post‐concussion symptoms in adults (16–60 years) with a mild traumatic brain injury (MTBI) 3 months and 1 year after injury.

Mild traumatic brain injuries: the impact of early intervention on late sequelae. A randomized controlled trial

SummaryBackground. Positive results from early clinical intervention of mild traumatic brain injury (MTBI) patients by rehabilitation specialists have been reported. Various treatments have been used, but few controlled studies are published. We hypothesised that early rehabilitation of selected MTBI patients would reduce long term sequelae.Method. A randomised controlled trial with one year follow-up. Among 1719 consecutive patients with MTBI, 395 individuals, 16–60 years of age, met the MTBI definition. Exclusion criteria were: previous clinically significant brain disorders and/or a history of substance abuse. The control group (n = 131) received regular care. The intervention group (n = 264) was examined by a rehabilitation specialist. 78 patients were mainly referred to an occupational therapist. The problems were identified in daily activities and in terms of post-concussion symptoms (PCS), an individualised, tailored treatment was given. Primary endpoint was change in rate of PCS and in life satisfaction at one-year follow-up between the groups.Findings. No statistical differences were found between the intervention and control groups. Patients who experienced few PCS two to eight weeks after the injury and declined rehabilitation recovered and returned to their pre-injury status. Patients who suffered several PCS and accepted rehabilitation did not recover after one year.Interpretation. In this particular MTBI sample, early active rehabilitation did not change the outcome to a statistically-significant degree. Further studies should focus on patients with several complaints during the first 1–3 months and test various types of interventions.

Cognitive outcome in children and young adults who sustained severe and moderate traumatic brain injury 10 years earlier

Objective: This study is a population-based, retrospective follow-up study of neuropsychological functions after severe and moderate TBI. Methods: One hundred and sixty-five survivors of TBI injured in 1987–1991 in the 0–17-year age group were identified. Of the traceable individuals (149), 53 patients who sustained injury at a mean of 9.96 years participated in a neuropsychological investigation 10 years post-injury. A control group of 40 healthy subjects, matched for age and sex was chosen. An extensive neuropsychological test battery was used. Results: The TBI group showed significantly poorer performance in tests of intellectual function, with substantially lower results in verbal tests and in tests of verbal learning and memory, visuo-constructive ability and executive functions. The severely injured group showed substantial recovery. Poor results in visuo-constructive tests and tests of executive functions remained. Conclusions: Severity of injury is an important factor when assessing outcome, even 10 years after childhood TBI. The TBI group obtained poorer results on most of the measurements compared with healthy controls. Verbal function was strongly affected which needs to be taken into consideration when preparing for rehabilitation programmes. Evaluations of final outcome should not be made before the subjects reach adulthood.

Neuropsychological progress during 14 years after severe traumatic brain injury in childhood and adolescence

Objective: To investigate the impact of time since injury on neuropsychological and psychosocial outcome after serious TBI in childhood or adolescence. Methods: The subjects were eight patients with serious TBI sustained at a mean age of 14 years who had been assessed neuropsychologically at 1, 7 and 14 years after TBI. A retrospective longitudinal design was chosen to describe the development in six neuropsychological domains on the basis of the assessments. Psychosocial data were gathered from clinical knowledge and a semi-structured interview 14 years after TBI. Results: Performance of verbal IQ shows a declining trend over the three assessments, that the performance of attention and working memory is low and that verbal learning is the cognitive domain which exhibits the largest impairments. The main psychosocial result is that three of the eight subjects went from a school situation with no adjustments to adult life with early retirement. Conclusions: Time since insult is an important factor when assessing outcome after TBI in childhood and adolescence and that assessment of final outcome should not be done before adulthood.

An overview of attention deficits after paediatric traumatic brain injury

Purpose: Attention could be categorized into sustained, selective, shifting, divided and attention span. The primary objective was to evaluate the type of attention deficits that occurs after paediatric traumatic brain injury. Methods: Keywords were used such as ‘attention’, ‘child’, ‘traumatic’, ‘brain’ and ‘injury’ on MEDLINE articles published in 1991–2009. Articles found through MEDLINE were manually cross-referenced. Main outcomes and results: Out of the examined categorizes, divided and sustained attention seem to be the most vulnerably, frequently displaying deficits in the children with TBI. Attention span seemed to be the most resistant and the shifting and selective categories falling somewhere in between. Most of the recovery is expected within the first year post-injury, even if some individuals continue to improve for years, and deficits often persist into adulthood. Conclusions: The attention domains are not affected to the same extent by TBI and this should be taken into consideration when evaluating a child. The commonly used tests also seem to differ in how sensitive they are in detecting deficits. The definition of attention domains and TBI would benefit to be stricter and agreed upon, to further facilitate research and rehabilitation programmes.

Occurrence of epilepsy during the first 10 years after traumatic brain injury acquired in childhood up to the age of 18 years in the south western Swedish population-based series

Background: The risk of seizures is increased after a traumatic brain injury (TBI), but the impact and duration of this increased risk is not well characterized in children. Objective: To identify post-traumatic epilepsy (PTE) and post-concussion symptoms 10 years after a TBI during childhood. Research design: The study is a population-based retrospective follow-up study. Procedure: Ten years after brain injury all 165 survivors, who as children (<18 years) in 1987–1991 as residents in the south western Swedish health care region had had a TBI, were invited to participate in a follow-up. A questionnaire regarding medical conditions and medication was filled out by the patients themselves or their parents as was a 21-item questionnaire (PCSQ) regarding post-concussion symptoms. Of the surviving 165 individuals, 109 participated (67%). Results: Eight of 109 developed immediate seizures. During the follow-up period 12/109 had developed active epilepsy. Of these 12, five had had immediate seizures. The incidence of developing PTE within 10 years after a TBI was thus in this series 11%. The relative risk to develop late onset post-traumatic epilepsy (≥1 week after injury) for those who had had immediate seizures was 9.018 (p = 0.0003, 95% CI = 3.69–22.05). Conclusions: TBI is a relatively rare cause of epilepsy in childhood, although immediate seizures are associated with an increased risk of developing post-traumatic epilepsy.

Long-term cognitive outcome after neurosurgically treated childhood traumatic brain injury

Objective: To explore the cognitive long-term outcome of two cohorts of patients neurosurgically treated for childhood traumatic brain injury (CTBI), either in 1987–1991 according to an older concept or 1997–2001 with a stronger emphasis on volume targeted interventions. Research design and methods: Participants in the two cohorts were subject to an extensive neuropsychological assessment, 13.2 and 6.1 years post-injury, respectively. In a between-group design, assessment results of the two cohorts, n = 18 and n = 23, were compared to each other and to controls. Data were analysed with multivariate analyses of variance. Results: Long-term cognitive deficits for both groups of similar magnitude and character were observed in both groups. Abilities were especially low regarding executive and memory function and verbal IQ. The cognitive results are discussed in terms of vulnerability of verbal functions and decreased executive control over memory-functions. Conclusions: There is a definite need for long-term follow-up of cognitive deficits after neurosurgically treated CTBI, also with the newer neurosurgical concept. Verbal learning and the executive control over memory functions should be addressed with interventions aimed at restoration, coping and compensation.

Variability in quality of life 13 years after traumatic brain injury in childhood

With the aim of describing variability in the long-term outcome of quality of life after neurosurgically treated pediatric traumatic brain injury, mostly self-reports of 21 individuals with mild or moderate/severe injury were gathered using Mayo-Portland Adaptability Inventory in telephone interviews 13 years aftyer injury. A majority of the participants reported brain injury-related problems. The median outcome on Mayo-Portland Adaptability Inventory was mild to moderate limitations. The variation within the moderate/severe group varied between relatively good outcome and moderate/severe limitations. Concentration, irritability, fatigue, and transportation were reported as the most problematic areas, whereas self-care was reported as well functioning. Societal participation appeared to be the best functional domain in this Swedish study. Examples of individual reports of the life-situation at various outcome levels were provided. Variability in outcome is large within severity groups, and research may gain by addressing both outcomes of the individuals and groups. Objective questions of outcome should be accompanied by questions of actual functioning in everyday life. To ensure long-term support for quality of life for those with remaining dysfunction after pediatric traumatic brain injury, healthcare systems should implement systematic routines for referral to rehabilitation and support.

Severe acquired brain injury: rehabilitation of communicative skills in children and adolescents.

The purpose of this study was to examine the use of a descriptive taxonomy for assessment of communicative abilities, the Pragmatic Protocol, in a rehabilitation setting with brain-injured children and adolescents. Eight severely brain-damaged children/youths were assessed with the Pragmatic Protocol during an intensive 6-week rehabilitation period. The nature and extent of communicative functioning was rated independently by a speech language pathologist and a rehabilitation assistant. The data suggests that the number of inappropriate pragmatic behaviours is relatively high, above all regarding aspects of speech/language and nonverbal communication. Interrater agreement reached approximately 95% considering nature of the communicative dysfunction in each patient. Results indicate the use of the Pragmatic Protocol as a useful tool to trace aspects of communicative competence in need of further, detailed exploration. Information concerning intact abilities is clarified and can be used in designing treatment.