Klaus Von Wild

Quality of Life after Brain Injury (QOLIBRI): Scale Validity and Correlates of Quality of Life

The QOLIBRI (Quality of Life after Brain Injury) is a novel health-related quality-of-life (HRQoL) instrument specifically developed for traumatic brain injury (TBI). It provides a profile of HRQoL in six domains together with an overall score. Scale validity and factors associated with HRQoL were investigated in a multi-center international study. A total of 795 adults with brain injury were studied from 3 months to 15 years post-injury. The majority of participants (58%) had severe injuries as assessed by 24-h worst Glasgow Coma Scale (GCS) score. Systematic relationships were observed between the QOLIBRI and the Glasgow Outcome Scale-Extended (GOSE), Hospital Anxiety and Depression Scale (HADS), and SF-36. Within each scale patients with disability reported having low HRQoL in two to three times as many areas as those who had made a good recovery. The main correlates of the total QOLIBRI score were emotional state (HADS depression and anxiety), functional status (amount of help needed and outcome on the GOSE), and comorbid health conditions. Together these five variables accounted for 58% of the variance in total QOLIBRI scores. The QOLIBRI is the first tool developed to assess disease-specific HRQoL in brain injury, and it contains novel information not given by other currently available assessments.

Examination of the safety and efficacy of an absorbable dura mater substitute (Dura Patch) in normal applications in neurosurgery.

Abstract Background The possibility of the transmission of Creutzfeldt-Jakob disease and slow virus infection (HIV) by cadaveric dura implants makes it necessary to find synthetic, absorbable substitute materials for plastic reconstruction of the dura mater. Dura-Patch is a bilayered composite of a dyed polydioxanone (PDS®) foil and an undyed fleece of Polyglactin 910 (Vicryl®) and PDS threads, known to be completely resorbable. Methods The Dura-Patch® was tested prospectively in 101 patients undergoing 75 supratentorial, 20 infratentorial, and 6 spinal operations in seven different neurosurgical departments. Fixation of the substitute was either by suturing, glueing, or both. The specific tissue properties were investigated considering biocompatibility, form, size, adaptability, fixation, scarring, and resistance to CSF tearing with the aid of hematologic and neurological parameters, CCT, and/or MRI scanning up to 6 months postoperatively. Results A total of 76 of 101 patients completed the study (75%). The biocompatibility of the Dura-Patch® with timely absorption of the implant material was excellent without exception. There was no notable local scarring and no infections. Transient CSF cushioning in 12.9% of the patients was in keeping with the normal range. The elasticity and flexibility of the Dura-Patch® was rated as “good” in 90% and was still better when the size of the implant increased, with an overall rating of handling as “good” or “excellent” in 97% of all operations. Conclusions The new absorbable Dura-Patch showed itself to be suitable for both plastic dura reconstruction and plastic extension of the subdural space with primary, watertight, germproof closure in routine intracranial and spinal tumor removal.

QOLIBRI Overall Scale: a brief index of health-related quality of life after traumatic brain injury

Background The Quality of Life after Brain Injury (QOLIBRI) scale is a recently developed instrument that provides a profile of health-related quality of life (HRQoL) in domains typically affected by brain injury. However, for global assessment it is desirable to have a brief summary measure. This study examined a 6-item QOLIBRI Overall Scale (QOLIBRI-OS), and considered whether it could provide an index of HRQoL after traumatic brain injury (TBI). Methods The properties of the QOLIBRI-OS were studied in a sample of 792 participants with TBI recruited from centres in nine countries covering six languages. An examination of construct validity was undertaken on a subsample of 153 participants recruited in Germany who had been assessed on two relevant brief quality of life measures, the Satisfaction With Life Scale and the Quality of Life Visual Analogue Scale. Results The reliability of the QOLIBRI-OS was good (Cronbachs α=0.86, test–retest reliability =0.81) and similar in participants with higher and lower cognitive performance. Factor analysis indicated that the scale is unidimensional. Rasch analysis also showed a satisfactory fit with this model. The QOLIBRI-OS correlates highly with the total score from the full QOLIBRI scale (r=0.87). Moderate to strong relationships were found among the QOLIBRI-OS and the Extended Glasgow Outcome Scale, Short-Form-36, and Hospital Anxiety and Depression scale (r=0.54 to -0.76). The QOLIBRI-OS showed good construct validity in the TBI group. Conclusions The QOLIBRI-OS assesses a similar construct to the QOLIBRI total score and can be used as a brief index of HRQoL for TBI.

Self-awareness and health-related quality of life after traumatic brain injury

Objective:To investigate the relations among self-awareness (SA), impaired SA, and health-related quality of life (HRQOL) after traumatic brain injury (TBI). Participants:One hundred forty-one adults hospitalized with TBI and their significant others from a cross-sectional multicenter study. Using Glasgow Coma Scale classification, 32 participants had severe injuries, 29 moderate, 44 mild, and 25 complicated mild TBI. Measures:Patient Competency Rating Scale for Neurorehabilitation; Short Form-36 Health Survey; Cognitive Quality of Life; Quality Of Life after Brain Injury; Hospital Anxiety and Depression Scale; Profile of Mood States; Glasgow Outcome Scale Extended. Method:Patient Competency Rating Scale for Neurorehabilitation ratings made by participants and their significant others were used to assess SA and discrepancies between the 2 ratings were used to define impaired SA. Results:Significant associations were identified between SA and HRQOL, anxiety, depression, and severity of injury. Participants with and without impaired SA differed in cognitive HRQOL and leisure activities. Using multiple regression, no direct predictors of SA were identified, although interaction effects were observed. Conclusion:After TBI, lower SA is associated with higher estimates of HRQOL, particularly in the cognitive domain. Although the associations are modest, the assessment of SA should play a role in the interpretation of reported HRQOL after TBI.

Neurorehabilitation Following Craniocerebral Trauma

Purpose:To review the quality management of functional neurorehabilitation in patients after craniocerebral trauma with an emphasis on factors that may explain variability of early and late outcomes after 1 year and how this might be influenced to improve health-related quality of life after traumatic brain injury (TBI).Methods:First ever prospective controlled, population- based, multicenter study on epidemiology of acute craniocerebral injuries (CCI) in Germany and analysis of acute medical care and functional rehabilitation with early and 1-year outcome. Catchment areas Hanover and Muenster (sum of inhabitants 2.114 million). The definition of acute CCI was according to the ICD-10: S-02, S-04, S-06, S-07, S-09 in combination with dizziness or vomiting, retrograde or anterograde amnesia, impaired consciousness, skull fracture, and/or focal neurologic impairment.Results:6,783 CCI patients (58% male) were admitted for emergency hospital treatment. 28% patients were < 1 to 15 years, 18% > 65 years of age. Completed questionnaires of 63.5% of the patients were analyzed. 1-year follow-up of two thirds of acute CCI. Incidence was 321/100,000. Initial CCI severity (Glasgow Coma Scale [GCS]) of 55% of patients showed 90.9% mild, 3.9% moderate, and 5.2% severe TBI. 5,221 patients (77%) were hospitalized, 1.4% of them died. Follow-up of 63.5%. Only 258 patients (3.8%) received neurologic-neurosurgical rehabilitation (73% male), 68% within 1 month after injury, 5% were < 16 years, 25% > 65 years of age. Early rehabilitation of 100 patients (39%), one fifth referred within first week. Outcome end of early rehabilitation phase “B”: Glasgow Outcome Scale (GOS) 1 = 4%; GOS 2 = 2.7%, GOS 3 = 37.3%, GOS 4 = 26.7%, GOS 5 = 29.3%, and end of rehabilitation “B–E”: GOS 1 = 1.2%, GOS 2 = 1.7%, GOS 3 = 21.8%, GOS 4 = 36.2%, and GOS 5 = 39.1%.Conclusion:Data on the epidemiology and quality management of early functional rehabilitation met the criteria set in 1992. Management of frequent multiple organ lesions and complications (57%) without referring the patient to another hospital and early functional outcome confirm the author’s concept of neurosurgical early rehabilitation.

Coping strategies in individuals after traumatic brain injury: associations with health-related quality of life

Abstract Purpose: This study investigates coping strategies after traumatic brain injury (TBI) and their associations with health-related quality of life (HRQoL). Methods: Participants were 141 adults followed up 3 months to 15 years after TBI of all severity degrees. Coping was assessed by the Freiburg Questionnaire of Coping with Illness (FQCI) and HRQoL by the Quality of Life after Brain Injury (QOLIBRI) scale and the Short Form-36 Health Survey (SF-36). Coping dimensions were extracted by principal component analysis. Multiple linear regression analysis was used to identify predictors of coping strategies. Results: Two factors for coping after TBI were extracted: Action/Distraction and Trivialisation/Resignation. The Trivialisation/Resignation strategy was negatively correlated with all aspects of HRQoL, while relationships with the Action/Distraction strategy were positive and significant for two domains. These two factors also showed significant associations with anxiety, depression, recovery, cognitive status, mood states and trauma severity. Multiple regression analysis identified recovery status as a predictor for the maladaptive Trivialisation/Resignation strategy. Conclusion: Two coping factors were identified, which were differentially associated with HRQoL. Maladaptive coping strategies play a particularly important role, and less reliance on such strategies is associated with better HRQoL; use of adaptive strategies should correspondingly be fostered. Implications for Rehabilitation This study highlights the relationship of coping strategies and HRQoL after TBI. For the assessment of HRQoL a novel disease-specific instrument was applied, that provides in detail TBI-relevant aspects of well-being and HRQoL. Individuals after TBI use two main sets of coping strategies that are differentially associated with HRQoL (and clinical variables). One is adaptive and the other maladaptive for HRQoL after TBI. Maladaptive and adaptive coping strategies used by the individual should be identified and considered in rehabilitation efforts to improve HRQoL after TBI.

Consensus of clinical neurorestorative progress in patients with complete chronic spinal cord injury.

Currently, there is a lack of effective therapeutic methods to restore neurological function for chronic complete spinal cord injury (SCI) by conventional treatment. Neurorestorative strategies with positive preclinical results have been translated to the clinic, and some patients have gotten benefits and their quality of life has improved. These strategies include cell therapy, neurostimulation or neuromodulation, neuroprosthesis, neurotization or nerve bridging, and neurorehabilitation. The aim of this consensus by 31 experts from 20 countries is to show the objective evidence of clinical neurorestoration for chronic complete SCI by the mentioned neurorestorative strategies. Complete chronic SCI patients are no longer told, “nothing can be done.” The clinical translation of more effective preclinical neurorestorative strategies should be encouraged as fast as possible in order to benefit patients with incurable CNS diseases. This manuscript is published as part of the International Association of Neurorestoratology (IANR) special issue of Cell Transplantation.

German validation of Quality of Life after Brain Injury (QOLIBRI) assessment and associated factors

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are still poorly understood, and no TBI-specific instrument has hitherto been available. This paper describes in detail the psychometrics and validity of the German version of an internationally developed, self-rated HRQoL tool after TBI—the QOLIBRI (Quality of Life after Brain Injury). Factors associated with HRQoL, such as the impact of cognitive status and awareness, are specifically reported. One-hundred seventy-two participants after TBI were recruited from the records of acute clinics, most of whom having a Glasgow Coma Scale (GCS) 24-hour worst score and a Glasgow Outcome Scale (GOSE) score. Participants had severe (24%), moderate (11%) and mild (56%) injuries as assessed on the GCS, 3 months to 15 years post-injury. The QOLIBRI uses 37 items to measure “satisfaction” in the areas of “Cognition”, “Self”, “Daily Life and Autonomy”, and “Social Relationships”, and “feeling bothered” by “Emotions”and “Physical Problems”. The scales meet standard psychometric criteria (α = .84 to .96; intra-class correlation—ICC = .72 to .91). ICCs (0.68 to 0.90) and αs (.83 to .96) were also good in a subgroup of participants with lower cognitive performance. The six-subscale structure of the international sample was reproduced for the German version using confirmatory factor analyses and Rasch analysis. Scale validity was supported by systematic relationships observed between the QOLIBRI and the GOSE, Patient Competency Rating Scale for Neurorehabilitation (PCRS-NR), Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Short Form 36 (SF-36), and Satisfaction with Life Scale (SWLS). The German QOLIBRI contains novel information not provided by other currently available measures and has good psychometric criteria. It is potentially useful for clinicians and researchers, in post-acute and rehabilitation studies, on a group and individual level.

Quality of life in persons after traumatic brain injury as self-perceived and as perceived by the caregivers

The primary aim of the study was to adopt QOLIBRI (quality of life after brain injury) questionnaire in a proxy version (Q-Pro), i.e., to use caregivers for comparison and to evaluate whether TBI patients’ judgment corresponds to that of their caregivers since the possible self-awareness deficit of the persons with TBI. A preliminary sample of 19 outpatients with TBI and their proxies was first evaluated with the Patient Competency Rating Scale to assess patients’ self-awareness; then they were evaluated with the QOLIBRI Patient version (Q-Pt) and a patient-centered version of the Q-Pro. Subsequently, 55 patients and their caregivers were evaluated using the patient-centered and the caregiver-centered Q-Pro versions. Q-Pt for assessing Quality of Life (QoL) after TBI, as patients’ subjective perspective and Q-Pro to assess the QoL of patients as perceived by the caregivers. The majority of patients (62.2%) showed better self-perception of QoL than their proxies; however, patients with low self-awareness were less satisfied than patients with adequate self-awareness. Low self-awareness does not impair the ability of patients with TBI to report on satisfaction with QoL as self-perceived.

Considerations for Experimental Neuromodulation Following Grafting of the Spinal Cord to Skeletal Muscles for Clinical Application

No current microsurgical approach has been clinically demonstrated to restore voluntary motor functioning distal to the site of spinal cord severance, for example, by direct reconnection of motor neurons within the cord tissue. Studies have shown that a number of different factors may account for the nonpermissiveness of the spinal cord environment and the limited functional regeneration of axons across the site of complete spinal cord damage. Building on the seminal work of David and Aguayo, Brunelli and colleagues showed that central axons are able to regenerate and extend long distances through a peripheral nerve graft, suggesting that they can regrow in an appropriate environment. However, their successfully tested and novel concept of peripheral nerve bypass grafting has not yet been implemented for further reconstructive experimental or clinical procedures for the treatment of brachial plexus or complete spinal cord injury. Their concept of central nervous system (CNS) single-cell plasticity remains a matter of ongoing debate. Neuroprotection and neuroplasticity following spinal cord injury are crucial for functional recovery and are dependent on CNS neuromodulation. Our transdisciplinary experimental study aimed to validate Brunelli’s paradigm in adult female Sprague–Dawley rats. We analyzed biochemical and histomorphological changes associated with CNS plasticity and neuromodulation to clarify the pathogenetic mechanisms underlying focal damage, as well as the interactions and overlap with neuroprotective and repair processes (i.e., endogenous defense activities). With this work, we hope to establish a robust new animal experimental paradigm that might be transferred later to clinical practice.