Nancy R. Mann

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

Insomnia in a post-acute brain injury sample

Objective : The purpose was to establish the frequency of insomnia within the post-acute TBI population and compare it with insomnia rates among other rehabilitation outpatients. Design : A prospective study was undertaken of 50 consecutive post-acute TBI admissions and a comparison group of 50 rehabilitation outpatients evenly divided between spinal cord injury (SCI) and musculoskeletal (MSK) cases. Setting : Subjects were recruited at various outpatient clinics of a major rehabilitation hospital. Patients : Among the TBI subjects, the predominant cause of injury was motor vehicle accident; both mild and severe injuries were well represented in the sample; and, on average, patients were almost 4 months post-injury. The comparison and TBI groups did not differ significantly with respect to education or marital status. However, the MSK group was older and a higher proportion of the SCI group was female. Measures : The Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and sleep diaries were administered to the TBI group. Only the PSQI and BDI were completed by the comparison group. Results : Thirty per cent of the patients were found to suffer from insomnia. Sleep initiation was a problem almost twice as often as sleep duration. An additional 12% did not meet the DSM-IV criteria for insomnia but, nevertheless, experienced a degradation of sleep quality, as measured by the PSQI. Conversely, only slightly more than half (58%) of the TBI sample reported sleep to be relatively normal and satisfactory. Insomnia was also commonly reported by the patients in the rehabilitation comparison groups. They generated significantly higher mean PSQI Global Scores relative to the TBI group and the frequency of poor sleep quality was elevated significantly above the TBI rate. Relative to the TBI cases, twice as many comparison group patients were classified by the PSQI as insomniacs. Conclusion : Poor sleep quality and insomnia were definitely problems for the TBI group, although the magnitude of these problems was much greater for the rehabilitation comparison group. Degraded and disordered sleep may represent widespread challenges within the rehabilitation population in general.

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.

Amantadine: a potential treatment for the minimally conscious state.

Pharmacologic strategies have been advocated to enhance the neurorehabilitation of persons with severe traumatic brain injury. Dopaminergic pathways have been felt to play a significant role in arousal. Employing single case design methodology we present the case of a survivor of severe traumatic brain injury who appeared to have a dose dependent response to the pro-dopaminergic medication amantadine. Further research is necessary to clarify the role of pharmacotherapy in the improvement of functional outcome.

Brain injury as a result of violence: Preliminary findings from the traumatic brain injury model systems

OBJECTIVES To identify possible risk factors that may predispose individuals to violent traumatic brain injury (TBI) and to determine the effect of etiology of injury on outcomes. STUDY DESIGN Prospective, longitudinal multicenter study. SETTING TBI Model Systems (TBIMS) located at Wayne State University/Rehabilitation Institute of Michigan, Detroit, MI; The Institute for Rehabilitation and Research, Houston, TX; Medical College of Virginia, Richmond, VA; and Santa Clara Valley Medical Center, San Jose, CA. SUBJECTS Individuals treated in the four TBIMS programs between 3/89 and 9/96 who met the criteria for inclusion in the TBIMS National Database and for whom the etiology was known (n=812). MAIN OUTCOME MEASURES Functional Independence Measure, Alcohol Quantity Frequency Variability Index, Community Integration Questionnaire. RESULTS Individuals who incur violence-related TBI tend to be male, nonwhite, unmarried, living alone, less educated, and unemployed at time of injury. They tend to have less severe brain injuries and better motor function at the time of admission to inpatient rehabilitation. At 1 year postinjury, they score lower on community integration measures; however, no difference exists in functional status. Etiology of injury was found to only play a minor role in the prediction of social and productive integration at 1 year postinjury. CONCLUSIONS Survivors of violent and nonviolent TBI have similar functional outcomes; however, they differ in preinjury and postinjury socio-economic characteristics, injury severity, and postinjury community integration. Socio-economic factors appear to play a large role in the risk for violent injury and in community integration following injury.

Factors associated with insomnia among post-acute traumatic brain injury survivors

This study investigated the relationships between insomnia and select demographic, injury and psychosocial variables in post-acute, traumatic brain injury. Clinical assessment of sleep and mood was undertaken via objective measures and a diagnostic interview among 91 consecutive brain injury admissions to an outpatient neurorehabilitation clinic. No associations between insomnia and gender, education, age, and time since injury were found. A logistic regression model of insomnia prediction based upon the Beck Depression Inventory (BDI), self-reported pain disturbance, litigation and Glasgow Coma Score (GCS) correctly classified 87% of the sample with respect to the presence or absence of insomnia; however, depression and injury severity were the only variables that made a significant unique contribution to the prediction of insomnia. It is concluded that among post-acute traumatic brain injury patients, insomnia is linked with both the presence of depression and a history of milder brain injuries. This suggests that the determinants of insomnia may differ from the acute to the post-acute phase, with neurological factors playing a primary role early in the recovery process and psychosocial factors ascending later. Therefore, assessment and treatment of insomnia must give careful attention to the larger psychosocial context in which the sleep disorder emerges, particularly to role of emotional disturbance.This study investigated the relationships between insomnia and select demographic, injury and psychosocial variables in post-acute, traumatic brain injury. Clinical assessment of sleep and mood was undertaken via objective measures and a diagnostic interview among 91 consecutive brain injury admissions to an outpatient neurorehabilitation clinic. No associations between insomnia and gender, education, age, and time since injury were found. A logistic regression model of insomnia prediction based upon the Beck Depression Inventory (BDI), self-reported pain disturbance, litigation and Glasgow Coma Score (GCS) correctly classified 87% of the sample with respect to the presence or absence of insomnia; however, depression and injury severity were the only variables that made a significant unique contribution to the prediction of insomnia. It is concluded that among post-acute traumatic brain injury patients, insomnia is linked with both the presence of depression and a history of milder brain injuries. This suggests that the determinants of insomnia may differ from the acute to the post-acute phase, with neurological factors playing a primary role early in the recovery process and psychosocial factors ascending later. Therefore, assessment and treatment of insomnia must give careful attention to the larger psychosocial context in which the sleep disorder emerges, particularly to role of emotional disturbance.

Demographic and social characteristics of the traumatic brain injury model system database

This article presents the following information on the 325 individuals included in the traumatic brain injury (TBI) model system database: (1) demographic and social characteristics; (2) the etiology of TBI (or cause of injury); and (3) the relationship among demographic factors, etiology, and facto

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.

Factors Affecting Hospital Length of Stay and Charges Following Traumatic Brain Injury

Objective:To examine the effect of Initial severity of traumatic brain injury (TBI), level of functional Independence at admission to rehabilitation, medical complications, mechanism of injury, and payer source on hospital length of stay (LOS) and charges. Design:Cohort analysis. Setting:Inpatient rehabilitation. Patients:525 subjects from the National Institute on Disability and Rehabilitation Research TBI Model Systems National Data Base with relatively mild to severe TBI, an average Glasgow Coma Scale (GCS) score of 8.5 (SD=3.9), and average duration of impaired consciousness (DIC) of 15.1 days (SD=40.6). Intervention:Inpatient rehabilitation. Main Outcome Measures:Hospital LOS, hospital charges. Results:Persons with lower initial GCS scores generally reached the rehabilitation setting later and stayed longer than persons with higher initial GCS scores. Within each GCS level, lower initial Functional Independence Measure (FIM) scores were associated with longer acute care and rehabilitation LOS. For persons admitted to rehabilitation with relatively high or medium FIM scores, greater severity of injury resulted in relatively modest increases in rehabilitation LOS. In contrast, low admission FIM scores were associated with much longer rehabilitation LOS for patients with severe injuries, compared with those with relatively mild injuries. Initial GCS score, DIC, admission FIM, and acute LOS accounted for 48% (adjusted 7?2) of the variance in rehabilitation LOS and 42% of the variance In rehabilitation hospital charges. Of the medical complications examined, only neurologic complications and intracranial operations added significantly to the model, explaining an additional 2% of the variance in rehabilitation LOS. The effect of payer source on LOS is complicated by age as well as by severity and mechanism of injury. Conclusions:Age, severity of Injury, and medical complications are powerful predictors of rehabilitation LOS and hospital charges. Other factors, such as functional independence at rehabilitation admission and length of acute hospitalization, explain additional variance. None of these factors in isolation is able to sufficiently predict rehabilitation LOS or charges. Multidimensional analysis of these factors is necessary to plan or administer the delivery of brain injury services