Kertia Black

Relationship between Glasgow coma scale and functional outcome.

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Posttraumatic amnesia: Its relation to functional outcome

OBJECTIVE To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.

Sitting balance following brain injury : does it predict outcome?

Balance dysfunction is commonly observed following traumatic brain injury. There are many proposed predictors of functional outcome in the traumatic brain injury population. It was hypothesized that the degree of balance dysfunction on admission to rehabilitation would be a significant predictor of the need for assistance at discharge, as measured by the Functional Independence Measure (FIM). This study involved 237 cases of traumatic brain injury patients admitted to a rehabilitation unit between November 1989 and September 1996. Using a multiple regression model, controlling for age, initial Glasgow Coma Score (GCS), rehabilitation admission strength, sitting balance and standing balance, it was found that the degree of impairment in sitting balance at admission to rehabilitation was a significant predictor of Discharge FIM-Total (FIM-T) score (p < 0:0001) and also of selected elements from the Discharge FIM-Motor (FIM-M) score (p < 0:0005). The combination of age, initial admission GCS, rehabilitation admission strength, standing balance and sitting balance accounted for 29% of the variance in the Discharge Total FIM score. Among these, sitting balance was the second most powerful predictor of both selected elements of the Discharge FIM motor score and discharge FIM-T. Sitting balance predictive capacity was exceeded in power only by age. Impairments in sitting balance appear to have a significant impact on functional outcome. Emphasis on unique rehabilitation techniques to treat balance dysfunction in the adult TBI population is warranted.Balance dysfunction is commonly observed following traumatic brain injury. There are many proposed predictors of functional outcome in the traumatic brain injury population. It was hypothesized that the degree of balance dysfunction on admission to rehabilitation would be a significant predictor of the need for assistance at discharge, as measured by the Functional Independence Measure (FIM). This study involved 237 cases of traumatic brain injury patients admitted to a rehabilitation unit between November 1989 and September 1996. Using a multiple regression model, controlling for age, initial Glasgow Coma Score (GCS), rehabilitation admission strength, sitting balance and standing balance, it was found that the degree of impairment in sitting balance at admission to rehabilitation was a significant predictor of Discharge FIM-Total (FIM-T) score (p < 0.0001) and also of selected elements from the Discharge FIM-Motor (FIM-M) score (p < 0.0005). The combination of age, initial admission GCS, rehabilitation admission strength, standing balance and sitting balance accounted for 29% of the variance in the Discharge Total FIM score. Among these, sitting balance was the second most powerful predictor of both selected elements of the Discharge FIM motor score and discharge FIM-T. Sitting balance predictive capacity was exceeded in power only by age. Impairments in sitting balance appear to have a significant impact on functional outcome. Emphasis on unique rehabilitation techniques to treat balance dysfunction in the adult TBI population is warranted.

Functional outcome after violence related traumatic brain injury

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Students t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Penetrating head injury: a prospective study of outcomes.

Abstract The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement. [Neurol Res 2001; 23: 219-226]

Long-term medical care utilization and costs among traumatic brain injury survivors

Vangel SJ Jr, Rapport LJ, Hanks RA, Black KL: Long-term medical care utilization and costs among traumatic brain injury survivors. Am J Phys Med Rehabil 2005;84;153–160. Objective: To examine billing patterns and predictors of healthcare utilization and costs associated with traumatic brain injury. Design: Retrospective cohort study of healthcare billings for 63 survivors of traumatic brain injury, over a 19-mo period, using a state-sponsored Medicaid program. The relationship of indicators of injury severity and disability to billings and payments was investigated. Mean age at time of injury was 33 yrs. Mean highest Glasgow Coma Scale rating immediately after brain injury was 8. Results: A total of

Do calendars enhance posttraumatic temporal orientation?: a pilot study

795,635 was billed to Medicaid for 3,950 services and medications used. A total of

Blunt versus penetrating violent traumatic brain injury: frequency and factors associated with secondary conditions and complications.

281,897 was paid for these billings out of the Medicaid account studied. Billings were used for statistical analyses, as they were considered the most stable indicator of cost. Motor deficits at discharge from inpatient rehabilitation (FIM™ motor score) showed inverse relationships to total billings (rho = −0.42, P < 0.001), subcategories of billings reflecting equipment and supplies (rho = -.26, P = 0.020), and outpatient billings (rho = −0.27, P = 0.015). Change in FIM motor scores during inpatient rehabilitation was inversely associated with billings (rho = −0.40). Change in FIM motor scores provided unique information in predicting utilization after accounting for demographic characteristics and severity of injury. Conclusions: Motor disability and improvement during inpatient rehabilitation were significant predictors of billings after traumatic brain injury. Initial severity of brain injury was not a significant factor in utilization.

Revised trauma score: an additive predictor of disability following traumatic brain injury?

The purpose of this study was to determine the effectiveness of an in-room calendar to correct temporal disorientation in a brain-injured population. Thirty consecutive brain injured patients (16 traumatic, 14 non-traumatic) admitted to a brain injury rehabilitation unit were randomly assigned to either a group with in-room calendars (n = 14) or a group without calendars (n = 16). A baseline Temporal Orientation Test (TOT) score was obtained. Daily TOT scores were obtained for patients throughout their rehabilitation stay or until two consecutive normal scores were obtained. When orientation errors were made, they were corrected and the attention of the patient was drawn to the calendar. There were no statistically significant associations between group and age, gender or mean GCS (for patients with traumatic etiology). Only baseline length of post-traumatic amnesia (PTA) had a significant association with eventual emergence from PTA (as defined by a normal score on the TOT). Age and presence of calendar were not significant. In-room calendars have been espoused as orientation aides. The data from this pilot study suggest that calendars do not hasten re-orientation. This finding suggests that other widely held but not rigorously tested beliefs regarding cognitive rehabilitation may need to be examined.

Medical Complications Common to Spinal-Cord-Injured and Brain-Injured Patients

Objective:To compare types and frequency of medical complications and comorbidities associated with violence-related penetrating traumatic brain injury (TBI) as compared to violence-related blunt TBI. Method:Data were collected prospectively at four medical centers participating in the TBI Model Systems (TBIMS) of Care project. A total of 317 individuals met the inclusion criteria for the TBIMS (i.e., showed evidence of a TBI, were age 16 or older, presented to the TBIMS emergency department within 24 hours of injury, and received acute and rehabilitation services within the model system). Main Outcome Measures:Frequency of medical complications and comorbid diseases. Results:Patients with penetrating injuries suffered significantly higher rates of respiratory failure (P = .004), pneumonitis/pneumonia, (P = .002), skull fracture (P = .001), cerebrospinal fluid leak (P = .0005), and hypotonia (P = .001) than did patients with blunt injuries. Prediction of complications and comorbidities via multiple regression revealed that a penetrating violent injury and the severity of injury were independent predictors of a higher rate of medical complications, whereas age and gender did not account for unique variance in the equation. Conclusions:Penetrating injuries are associated with higher rates of certain medical complications, especially to the pulmonary and central nervous systems. Acute care physicians and physiatrists must be prepared to treat these complications more often in patients with penetrating injuries.