Jerry Wright

Functional measures after traumatic brain injury : ceiling effects of FIM, FIM+FAM, DRS, and CIQ.

Objective:The characteristics of the Disability Rating Scale (DRS), Functional Independence Measure (FIM), Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and Community Integration Questionnaire (CIQ) are examined, especially in regard to a “celling effect” after rehabilitation discharge (ie, how well each of the instruments detects meaningful change in level of function). Design:Data were collected prospectively at admission and discharge from acute inpatient rehabilitation and at years 1 and 2 after injury (the CIQ was collected only at years 1 and 2). Analyses are reported on a subsamplc of cases with listwise deletion, although the analyses were also done using all data available, and results compared to ensure stability of findings between samples. Setting:National database of the four Traumatic Brain Injury (TBI) Model Systems in San Jose, Calif; Detroit, Mich; Richmond, Va; and Houston, Tex. Patients:All consenting patients with TBI age 16 and older admitted to a Model System within 24 hours of Injury and receiving inpatient rehabilitation within the Model System qualified for the study. Data on 612 individuals were collected, with a minimum of 80 cases having complete data over time. Main Outcome Measures:The DRS, FIM, FIM+FAM, and CIQ. Results:There is a substantial ceiling effect of the FIM, even by inpatient rehabilitation discharge (ie, one half of the cases have an average score of 6 to 7 [“independent or modified independence—no helper] across the 18 FIM Items). The FIM+FAM shows a ceiling effect In one third of the cases. The DRS shows less ceiling effect at discharge, 1 year, and 2 years than the FIM or the FIM+FAM. CIQ scores have a ceiling effect on home and social integration subscales when compared with scores from a sample of individuals without disabilities. The productivity subscale remains well below the norm. Conclusions:Celling effects for the FIM, FIM+FAM, and two of the three CIQ subscales indicate that these measures are not as sensitive to changes, especially in the community, as may be needed to assess progress in areas most commonly causing dysfunction for the TBI population. More emphasis must be placed on improved measurement of relevant goals in the postacute and home settings with brief and precise scales

Patterns of fatigue and its correlates over the first 2 years after traumatic brain injury.

This study used a prospective longitudinal design to quantify fatigue and associated factors during the first 2 years after traumatic brain injury (TBI). Fifty-one individuals were assessed at 3 time points: within the first 6, 12, and 18–24 months after TBI. Self-reported fatigue improved during the first year, as did pain, sleep quality, cognitive independence, and involvement in productive activity. Further changes up to 2 years after TBI were not observed. The subset of individuals who reported significant increases in fatigue over the first 2 years demonstrated poorer outcomes in cognition, motor symptoms, and general functioning than those with decreased or stable fatigue.

The experience of fatigue in the first 2 years after moderate-to-severe traumatic brain injury: a preliminary report.

Fatigue is a well-recognized issue for individuals with traumatic brain injury (TBI). This prospective study examined the rate and types of fatigue that are experienced by a cohort of individuals with TBI within the first 2 years, using a multidimensional fatigue scale. The impact of factors such as demographics, injury severity indices, and concomitant psychosocial variables was also examined. Using 2 measures of overall fatigue, 16%–32% at Year 1 and 21%–34% at Year 2 reported significant levels of fatigue. Fatigue did not appear to change between 1 and 2 years post-TBI. Sleep quality was the most prevalent concomitant disturbance followed by depression and pain.

The Satisfaction With Life Scale.

The SWLS consists of 5-items that require a ratingon a 7-point Likert scale. Administration is rarely morethan a minute or 2 and can be completed by interview(including phone) or paper and pencil response. The in-strumentshouldnotbecompletedbyaproxyansweringfortheperson.Itemsofthe SWLSaresummedtocreatea total score that can range from 5 to 35.The SWLS is in the public domain. Permission isnot needed to use it. Further information regardingthe use and interpretation of the SWLS can be foundat the author’s Web site http://internal.psychology.illinois.edu/∼ediener/SWLS.html. The Web site alsoincludes links to translations of the scale into 27languages.

Traumatic brain injury with and without late posttraumatic seizures: what are the impacts in the post-acute phase: a NIDRR Traumatic Brain Injury Model Systems study.

Objective:To compare and contrast the levels of impairment, disability, and community participation of individuals with traumatic brain injury (TBI) with or without late posttraumatic seizures (LPTS). Design:Prospective survey study. Setting:Community. Participants:Two groups of 91 individuals with TBI, with and without LPTS, were enrolled in the TBI Model Systems National Database between 1989 and 2002 and interviewed at years 1, 2, and 5 postinjury. Interventions:Not applicable. Main Outcome Measures:Demographic, injury severity, productivity, and psychosocial outcomes. Results:The majority of the demographic and productivity outcomes up to 5 years postinjury were similar between individuals in the LPTS and non-LPTS groups. Both the LPTS and non-LPTS groups showed an increasing percentage of individuals who began to live alone after the first year postinjury and a decreasing percentage of individuals who were living with family members at 5 years postinjury compared with the first year post-TBI. A higher percentage of individuals in the LPTS group reported using more dependent forms of transportation such as riding with others or using public transportation. Individuals in the LPTS group had higher Disability Rating Scale scores at all time points, denoting greater functional disability, than individuals in the non-LPTS group, despite the 2 groups having similar Disability Rating Scale scores at discharge from rehabilitation. Satisfaction With Life Scale scores showed no changes over time but were significantly different between both groups at all time points, with individuals in the LPTS group reporting lower Satisfaction With Life Scale score than individuals in the non-LPTS group. Conclusions:It does appear that the development of LPTS following a TBI is associated with poorer functional and psychosocial outcomes in the first 5 years after injury. It remains to be determined whether there are other factors that also may account for these differences and that may be amenable to intervention.

Traumatic Spinal Cord Injuries in Horseback Riding: A 35-Year Review

Background: Spinal cord injury (SCI) is a potentially disabling neurologic injury that can occur in horseback riding. To date, no published study has examined the epidemiology of SCI from horseback riding in the United States, and few international studies exist on this topic. Several studies have described traumatic brain injuries, spine fractures, and extremity injuries; however, SCI patterns and outcomes in horseback riders are poorly understood. Purpose: This study was undertaken to characterize the demographics, SCI patterns, and neurologic outcomes of persons with SCIs related to horseback riding. Study Design: Descriptive epidemiologic study. Methods: This is a retrospective review of 121 SCI cases from horseback riding in the National SCI Statistical Center database from 1973 to 2008. The treatment setting was 26 U.S. SCI Model Systems of Care. The number of injuries, gender, age, and SCI type for horseback riding were compared with other sports and activities. The level of preserved neurologic function, SCI completeness, American Spinal Injury Association classification, and mechanical ventilation use at discharge were examined in the horseback riding group. Results: The mean age of injury was 37.8 years (standard deviation, 15.2). The majority of patients were white (88%) and female (50.4%). Compared with diving, motorcycle riding, football, and gymnastics, horseback riding involved a significantly higher number of women (P < .005), a higher mean age of injury, and an equal likelihood of resulting in paraplegia and tetraplegia. The most common levels of preserved neurologic function were C4-C6, T12, and L1. Spinal cord injury from horseback riding most commonly resulted in incomplete tetraplegia (41%) followed by complete paraplegia (24%). Only 4 patients required mechanical ventilation on discharge from acute inpatient rehabilitation. Conclusion: Spinal cord injury from horseback riding affects an equal proportion of women and men, has a wide age range, and most commonly results in incomplete tetraplegia followed by complete paraplegia. Study findings improve awareness of the demographics and neurologic outcomes of individuals with SCI from horseback riding and can help guide future studies evaluating SCI mechanisms in horseback riders to improve injury prevention and management.

Mortality in Late Post-Traumatic Seizures

The objective of this study was to examine the mortality rates in individuals with traumatic brain injury (TBI) who were classified as having experienced late post-traumatic seizures (LPTS) in the first 2 years post-TBI compared to those who were seizure-free (non-LPTS). Participants were a pooled sample (n = 508) from two studies which enrolled individuals with TBI who were injured between March 31, 1992 and December 20, 1999. The first sample was made up of individuals enrolled in a study of risk factors for LPTS development; the second sample was composed of individuals enrolled in the TBI National Database from a single rehabilitation center. Seventy-one (14%) participants had LPTS, of which 27% had died at 8-15 years post-injury, as compared to 10% of non-LPTS participants. Individuals with LPTS died at a younger age (54.1 versus 67.7 years; p = 0.01), but there were no statistically significant differences in either time from date of injury to death or highest GCS score in the first 24 h. Causes of death were variable and not specifically related to epilepsy. Of those with LPTS, risk factors for death include advanced age at time of injury and presence of subdural hematoma. The higher mortality rate and death at younger age with variable causes in TBI individuals with LPTS warrant close medical evaluation and monitoring of these individuals, particularly accessibility and compliance with ongoing general medical care, and education of primary care colleagues of the unique needs of this at-risk population.

Disability Rating Scale

T DISABILITY RATING SCALE (DRS) is an 8-item outcome measure that is one of the more frequently used measures in traumatic brain injury (TBI) research.1 The scale is sometimes referred to as the Rappaport DRS to discriminate the Disability Rating Scale from the Dementia Rating Scale (also abbreviated DRS). The popularity of the DRS is derived from its brief administration time, its usefulness in a large variety of settings or levels of care, its widespread acceptance and use in research, and its free availability in the public domain. The DRS was designed to measure changes in recovery in adults with TBI, where total scores are meant to reflect a level of disability.2 It has been recommended as a useful outcome measure for clinical trials involving individuals with brain injury and is currently classified as a Supplemental Measure within the National Institute of Neurological Disorders and Stroke Common Data Elements Project (www.commondataelements.ninds.nih. gov). The DRS has also been used to validate other brain injury outcome scales, including the Coma Recovery Scale, Mayo Portland Adaptability Inventory, Supervision Rating Scale, and the Community Integration Questionnaire.3 Because of the brief administration time, one important benefit of the DRS is the efficiency at which it can be administered and the ability for researchers to complete it over the phone. The DRS is also unusual in that it has the ability to describe disability for individuals in a wide variety of settings, from acute care hospitals

Impact of late post-traumatic seizures on physical health and functioning for individuals with brain injury within the community.

Primary objective: To better characterize, describe and highlight issues that individuals with TBI and active LPTS may face in their daily lives. Design: Prospective multi-centre mixed method qualitative and quantitative interview. Participants: Twenty-five individuals, 5–13 years post-injury, who had reported having LPTS and TBI. Measures: Disability Rating Scale (DRS); Supervision Rating Scale (SRS); Glasgow Outcome Scale–Extended (GOS-E); Perceived Stress Scale (PSS); Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF) sub-scales: Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration; and Craig Hospital Inventory of Environmental Factors (CHIEF); and qualitative interview questions pertaining to management of the seizure disorder and its effect on the individuals health, function, community integration and participation. Results: Data are presented regarding seizure activity and management; return to driving post-seizure; coping and participation; and standardized outcome measures. Conclusions: Individuals with TBI and LPTS are at a double-barrelled disadvantage regarding ongoing physical, cognitive, psychosocial and reintegration issues following brain injury and epilepsy. Clearer clinical guidelines and treatment strategies need to be developed to help ameliorate these ongoing issues. Additional research is needed to identify what the rehabilitation community can do to continue to facilitate people living safely and independently.

An effective community-based mentoring program for return to work and school after brain and spinal cord injury

Information is presented on a community-based mentoring program, developed to work with existing community agencies and provide structure to the frequently confusing network of services for young adults, ages 16 to 26 years, with a recently acquired disability including TBI, SCI, and other neurological disorders. The over-arching goal of the Mentoring Program was to improve the ability of individuals with disabilities to access and maximally utilize the services and programs that are available in the community. The two objectives of this study were: (1) to demonstrate continuing increases in standardized measures of community integration from the time of enrollment in the program to the time of exit from the program, and (2) to improve the percentage of youth and young adults with disabilities who successfully access post-secondary education or employment opportunities. 53 participants had post-secondary education as a goal. 12 participants had an employment goal. 12 participants had both education and employment as a combined goal. It was not uncommon for participants to change goals. Of those with education goals, 23/53 achieved educational goals and 7/53 achieved employment goals. Of those with vocational goals, 5/12 achieved vocational goals and 1/12 achieved educational goals. Of those with both goals, 5/12 achieved educational goals and 1/12 achieved vocational goals. Significant community integration and independence improvements were noted for program participants (CHART Mobility and Cognitive Independence, M2PI, DRS, and SRS). Overall, findings suggest that mentoring can be beneficial toward achieving the goals of post-secondary education, employment and community independence for individuals with disabilities; specifically those with traumatic brain injury, spinal cord injury and other neurological disorders.