John Olver

Outcome following traumatic brain injury: a comparison between 2 and 5 years after injury

This study examined long-term outcome in traumatically brain-injured individuals following discharge from a comprehensive rehabilitation programme. Of 254 traumatic brain injury (TBI) patients reviewed at 2 years, 103 have been followed up at 5 years using a structured interview format detailing neurological symptoms, mobility, independence in ADL, productivity status, relationship issues, communication and the presence of cognitive, behavioural and emotional changes. Visual difficulties, headache and fatigue were persistent in a significant number of patients. Between 2 and 5 years there was increased independence in personal, domestic and community ADL and the use of transport. Ten more patients had returned to driving. On the other hand there was a slightly higher incidence of cognitive, behavioural and emotional changes reported at 5 years. Thirty-two per cent of those working at 2 years were not employed at 5 years. Many students had also become unemployed. These findings suggest the need for intermittent lifelong intervention following TBI. Systems of rehabilitation need to be adapted to provide this.

A profile of outcome: 2 years after traumatic brain injury

A group of 175 traumatic brain injury (TBI) patients who had undergone intensive rehabilitation at Bethesda Hospital attended a follow-up interview 2 years after injury. The majority of patients had suffered severe TBI. Outcome was documented in ten areas: medical/physical, mobility, activities of daily living (ADLs) accommodation, marital status, leisure and recreation, employment/study, communication, cognition and behaviour. Whilst most patients were physically independent and competent in personal and domestic activities of daily living, a third of the group were still reliant on assistance with community skills and transport, and more than half of those who previously had a job, were not working at 2 years post-injury. Around two-thirds of the sample reported cognitive, behavioural and emotional changes. There is clearly a need for ongoing community-based support and assistance in dealing with practical difficulties and psychological problems as they are experienced after return to the community.

Long-term adjustment of families following traumatic brain injury where comprehensive rehabilitation has been provided

Objectives : The present study aimed to examine long-term family and emotional adjustment in close relatives of individuals with TBI, who had access to comprehensive rehabilitation services. It also examined the relative influence thereon of factors including injury severity, handicap and cognitive and behavioural changes in the injured person, relationship with the injured person and caregiver status. Methods : Participants were 143 TBI individuals and their close relatives. They completed the Family Assessment Device (FAD), Leeds Scales of Anxiety and Depression, Structured Outcome Questionnaire, CHART, SIP Psychosocial Dimension and Novaco Anger Control Questionnaire 2-5 years post-injury. Results : Results showed that families were, on average, functioning in the normal range on the FAD. Anxiety and depression were more likely to be present in those responsible for care of their injured relative. There were no differences between spouses and parents. Presence of cognitive, behavioural and emotional changes was the strongest predictor of anxiety and depression in relatives and of unhealthy family functioning. Conclusions : Every attempt should be made to develop models of long-term support and care that alleviate these sources of burden on relatives.

Botulinum toxin assessment, intervention and aftercare for lower limb disorders of movement and muscle tone in adults: international consensus statement

Lower limb disorders of movement and muscle tone in adults significantly impact quality of life. The management of the patient with hypertonia is complex and requires a multidisciplinary team working with the patient and family/carers. Botulinum neurotoxin type A (BoNT‐A) has been used as a component of this management to reduce lower limb hypertonia, increase passive range of motion and reduce associated pain and requirements for bracing. Adjunctive treatments to augment the effect of BoNT‐A include electrical muscle stimulation of the injected muscles and stretching. When determining suitability for injection, the patient’s main goals for intervention need to be established. Muscle overactivity must be distinguished from contracture, and the effect of underlying muscle weakness taken into account. Explanation of the injection process, potential adverse effects and post‐injection interventions is essential. Assessment at baseline and post‐treatment of impairments such as hypertonia, range of motion and muscle spasm are appropriate; however, the Goal Attainment Scale and other validated patient‐centred scales can also be useful to assess therapy outcomes. In the future, initiatives should be directed towards examining the effectiveness of BoNT treatment to assist with achievement of functional and participation goals in adults with hypertonia and dystonia affecting the lower limb.

A longitudinal study of family functioning after TBI and relatives' emotional status

The objectives of the study were to examine family functioning and relatives emotional state after traumatic brain injury (TBI), and to test a model of the relationship between neurobehavioural status, family functioning and relatives emotional status at two and five years post-injury. The relatives of 98 adult individuals who had sustained severe TBI were followed up 2 and 5 years post-injury and completed the Family Assessment Device, the Hospital Anxiety and Depression Scale, and rated the neurobehavioural status (cognitive, behavioural, emotional, social) of their injured relative, using the Structured Outcomes Questionnaire. A structural equation model, based on existing research, was developed and tested on 66 of the participants. The level of family functioning and the rates of clinically relevant levels of anxiety and depression did not change over time (pu2009>u2009.05). The starting path model was revised. The final model had an excellent fit, χ2(16)u2009=u200915.20, pu2009=u2009.51; CFIu2009=u20091.00, RMSEAu2009<u2009.001, p for test of close fitu2009=u2009.66. In this model, poor family functioning and symptoms of anxiety and depression in the relatives were predicted by behavioural and mood changes in the injured individual. The relationship between family functioning and relatives mood was reciprocal. The findings suggest the need for timely investigation and institution of interventions. Support is needed both for individual family members in dealing with their emotional distress as well as for the family as a whole, with the aim of maximising quality of life for those with TBI and their relatives.

Evaluation of a community-based model of rehabilitation following traumatic brain injury

In recent years there has been a growing trend towards community-based post-acute rehabilitation for individuals with traumatic brain injury (TBI), as opposed to the traditional centre-based model, based on the premise that these individuals will learn more effectively in settings where they usually have to perform. In the present study, outcomes at two years post-injury in 77 individuals with TBI, treated within the community were compared on measures of activities of daily living (ADL), vocational status, and emotional adjustment with those of 77 TBI patients individually matched for gender, age, education, occupation, post-traumatic amnesia (PTA) duration, Glasgow Coma Scale (GCS) score and time in inpatient rehabilitation, who had attended the hospital for outpatient therapy. There were no significant differences between groups in terms of employment outcomes or independence in personal or domestic ADL. However those treated in the community were less likely to be independent in shopping and financial management and reported more changes in communication and social behaviour. Due to constraints of time and resources, these patients had received fewer one-on-one therapy sessions and thus treatment costs were somewhat lower. Attendant care costs were also lower in the community treatment group. Strengths and weaknesses of community-based post-acute rehabilitation are discussed.

Spatiotemporal deficits and kinematic classification of gait following a traumatic brain injury: a systematic review.

Objective:To identify the key biomechanical gait abnormalities resulting from traumatic brain injury (TBI) and determine whether the abnormalities support a system for the classification of gait disorders. Design:Systematic review with data from quantitative studies synthesized in a narrative format. Participants:Adults with TBI. Outcome measures:Spatiotemporal, kinematic, and kinetic parameters of classification systems. Results:The search identified 38 articles that reported on various methods for gait assessment in TBI. Three-dimensional gait analysis (3DGA) was used in 15 studies, primarily to quantify spatiotemporal parameters. Results revealed that people with a TBI walked more slowly with shorter steps and greater mediolateral sway following TBI. Stepping over obstacles, walking with eyes closed, or performing dual tasks accentuated gait deficits. Only one small study reported kinematic data for the major lower limb joints in 8 well recovered patients. One further study used 3DGA to classify the gait patterns of people with TBI but this classification was based on methods developed for stroke and cerebral palsy. No studies attempted to develop a classification system on the basis of the gait disorders of people with TBI. Conclusion:Although the studies were generally of high quality, little is known about the nature of gait disorders following TBI. Classification based on systematic description of gait disorders following TBI has not been attempted.

Outcome Measurement in an Inpatient and Outpatient Traumatic Brain Injury Rehabilitation Programme

This paper outlines approaches taken to the measurement of outcome from a rehabilitation programme for individuals with traumatic brain injury (TBI). It describes methods used to evaluate progress made by individuals towards the attainment of goals within the programme, including the use of a Role Checklist and Goal Attainment Scaling. Maintenance of gains and long-term outcome in a range of life domains over 5 years after injury has been documented using a structured questionnaire, on which we obtained good inter-rater reliability. By 5 years after injury, the majority of individuals with TBI were in reasonable agreement with their close others regarding the presence of cognitive and behavioural changes. Standardised measures used in addition to the structured questionnaire have included the Sickness Impact Profile, the Craig Handicap Assessment and Reporting Technique (CHART), and the Leeds Scales for the Self-assessment of Anxiety and Depression. Findings and inter-correlations of all these measures ar...

SAFETY OF METHYLPHENIDATE FOLLOWING TRAUMATIC BRAIN INJURY: IMPACT ON VITAL SIGNS AND SIDE-EFFECTS DURING INPATIENT REHABILITATION

OBJECTIVEnThe aim of the present study was to evaluate the safety of methylphenidate administered during inpatient rehabilitation following traumatic brain injury.nnnMETHODSnForty inpatients with moderate-severe traumatic brain injury (mean 68.4 days post-injury) participated in a randomized, cross-over, double-blind, placebo-controlled trial of methylphenidate administered at a dose of 0.3 mg/kg body weight twice daily.nnnRESULTSnMethylphenidate administration resulted in a statistically significant increase in pulse of 12.3 beats/min (95% confidence interval (CI) 9.25-15.36), diastolic blood pressure of 4.1 mmHg (95% CI 2.11-6.10), and mean arterial pressure of 3.75 mmHg (95% CI 1.79-5.72). These changes did not, however, appear to be symptomatic, as no participants were withdrawn due to adverse events, and there was no significant self-report of increased heart rate with methylphenidate. Blinding was successful. Significantly greater reporting of irritability of 0.14 points (95% CI 0.02-0.26), difficulty sleeping of 0.17 points (95% CI 0.02-0.31) and total side-effects of 0.68 points (95% CI 0.06-1.30) was associated with methylphenidate compared with placebo.nnnCONCLUSIONnMethylphenidate given at 0.3 mg/kg body weight appears to be safe in the inpatient rehabilitation phase. This trial is registered with the Australian New Zealand Clinical Trials Registry (12607000503426).

Stroke Rehab Down Under: Can Rupert Murdoch, Crocodile Dundee, and an Aboriginal Elder Expect the Same Services and Care?

Abstract Australia is the world’s sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings – in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia’s 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.