Sara Laxe

Developing Core Sets for Persons With Traumatic Brain Injury Based on the International Classification of Functioning, Disability, and Health:

The authors outline the process for developing the International Classification of Functioning, Disability, and Health (ICF) Core Sets for traumatic brain injury (TBI). ICF Core Sets are selections of categories of the ICF that identify relevant categories of patients affected by specific diseases. Comprehensive and brief ICF Core Sets for TBI should become useful for clinical practice and for research. The final definition of the ICF Core Sets for TBI will be determined at an ICF Core Sets Consensus Conference, which will integrate evidence from preliminary studies. The development of ICF Core Sets is an inclusive and open process and rehabilitation professionals are invited to participate.

What domains of the International Classification of Functioning, Disability and Health are covered by the most commonly used measurement instruments in traumatic brain injury research?

OBJECTIVE To identify the most frequently used outcome measurement instruments reported in clinical studies on TBI and to provide a content comparison in the framework of the International Classification of Functioning, Disability and Health (ICF). PATIENTS AND METHODS A systematic literature review of clinical studies in TBI was performed using Medline, EMBASE and PsychINFO. The items of the measurement instruments present in more than 20% of the studies were linked to the ICF language. RESULTS 193 papers fulfilled the eligibility criteria. The frequency analysis identified six instruments: Functional Independence Measure (50%), Glasgow Outcome Scale (34%), Disability Rating Scale (32%), Wechsler Adult Intelligence Scale (29%), Trail Making Test (26%) and Community Integration Questionnaire (22%). The analysed instruments focus on different aspects of body functions (especially DRS, WAIS and TMT) and aspects of activities and participation in life (especially CIQ and FIM). Inter-researcher agreement for the ICF linking process was 0.83. CONCLUSIONS Translating the items of different measurement instruments into the ICF language provides a practical tool to facilitate content comparisons among different outcome measures. The comparison can assist clinical researchers to integrate information acquired from different studies and different tools.

Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups

Purpose: To describe problems in body functions, activities, and participation and the influence of environmental factors as experienced after mild traumatic brain injury (TBI), using the ICF framework. To compare our findings with the Brief and Comprehensive ICF Core Sets for TBI. Methods: Six focus-group interviews were performed with 17 participants (nine women, eight men, age ranged from 22 to 55 years) within the context of an outpatient rehabilitation programme for patients with mild TBI. The interviews were transcribed verbatim and analysed using the ICF. Results: One-hundred and eight second-level categories derived from the interview text, showing a large diversity of TBI-related problems in functioning. Problems in cognitive and emotional functions, energy and drive, and in carrying out daily routine and work, were frequently reported. All ICF categories reported with high-to-moderate frequencies were present in the Brief ICF Core Set and 84% in the Comprehensive ICF Core Set. The reported environmental factors mainly concerned aspects of health and social security systems, social network and attitudes towards the injured person. Conclusions: This study confirms the diversity of problems and the environmental factors that have an impact on post-injury functioning of patients with mild TBI. Implications for Rehabilitation Disabilities related to cognitive and emotional functions, energy and drive, and carrying out daily routine and work should be addressed in rehabilitation of people with mild traumatic brain injury (TBI). Attention should be given to environmental facilitators and barriers for activities and participation. Participation in everyday life after a mild TBI, including social- and work-participation, constitutes a challenge where multidisciplinary rehabilitation efforts should be considered. The Brief Core Set does not attain all frequently observed categories of functioning among people with mild TBI.

ICF use to identify common problems on a TBI neurorehabilitation unit in Spain

OBJECTIVE To describe functioning and health of individuals with traumatic brain injury (TBI) based on the International Classification of Functioning, Disability and Health (ICF). METHODS A cross-sectional, prospective study was conducted in a neurorehabilitation hospital. Data collection included socio-demographic factors, single interviews based on the extended ICF Checklist 2.1 for TBI, patient ratings on general health and functioning status, WHOQoL, EQ5D and the Comorbidity Questionnaire. RESULTS 103 patients (81%males) were included in the study. The mean of age was 34 yrs. 24% were inpatients whereas 76% were outpatients. 130 out of 150 categories (87%) of the extended checklist were relevant in > 10% of patients. Differences in functioning and disability between patients in the shorter versus long term situation were noted to be predominantly in the ICF domains of Activities and Participation as well as in Body Functions. Correlations between EQ5D and ICF-based data collections were all p < 0.01. CONCLUSIONS This study identified the most common problems in patients with TBI receiving Neurorehabilitation services based on the ICF. Results emphasize the need to describe disability and rehabilitation standards from a comprehensive perspective that not only includes Body Functions and Structures but also the ICF domains of Activities and Participation and Environmental factors.

Development of the International Classification of Functioning, Disability and Health core sets for traumatic brain injury: An International consensus process

Background: In a patient-oriented healthcare system, the integration of the functional status of the patient from the perspective of different professionals is understandable by the use of the International Classification of Functioning, Disability and Health. Objective: A formal decision-making and consensus process is presented to develop the first version of the International Classification on Functioning, Disability and Health (ICF) Core Sets for Traumatic Brain Injury. Method: A panel with the results from preparatory studies that included a literature review, a qualitative study, empirical data collection and an expert survey, was presented. A consensus conference was held in Barcelona, March 2010 and 23 professionals attended representing nine countries. Results: The preparatory studies identified 183 eligible categories. After the voting process, 139 constituted the Comprehensive Core Sets for TBI and 23 the Brief Core Sets for TBI. Conclusions: The consensus conference led to the integration of evidence and expert opinion based on the ICF. The adoption of the ICF Core Sets for TBI provides a basic international standard for the multidisciplinary assessment of a TBI patients functioning.

How does dysautonomia influence the outcome of traumatic brain injured patients admitted in a neurorehabilitation unit

Abstract Background: Patients surviving severe traumatic brain injury (TBI) may suffer from symptoms presumed to be related to an excessive sympathetic production known as paroxysmal sympathetic hyperactivity (PSH). While this condition is more common in the acute phase, prognosis is less clear in rehabilitation settings. Aim: The goal of this study is to describe the functional status of patients with PSH admitted in a rehabilitation hospital and to determine its prognostic influence during rehabilitation. Methods: A cohort study was undertaken of all the patients admitted in a neurorehabilitation hospital suffering from PSH. Functional outcomes were reported according to the Glasgow outcome scale-extended (GOSE), the Disability Rating Scale (DRS) and the Functional Independence Measure (FIM). Results: Thirteen out of 39 patients suffered symptoms compatible with PSH. Neuroimaging of PSH patients showed more diffuse lesions. The FIM at admission was lower in the PSH group who was transferred for rehabilitation at an earlier stage. At discharge no differences were seen using the FIM, DRS and GOS-E. Conclusions: Functional status is similar and PSH does not appear to influence recovery during the rehabilitation, although PSH patients are more likely to undergo psychoactive medications and special care is needed to approach their caregivers that perceive PSH as a complication for rehabilitation.

ICF profiling of patients with traumatic brain injury: an international professional survey

Abstract Purpose: A worldwide internet survey was conducted (1) to identify problems of individuals with traumatic brain injury (TBI) addressed by health professionals and (2) to summarize these problems using the International Classification of Functioning, Disability and Health (ICF). Method: A pool of professionals involved in the TBI rehabilitation process that included physicians, nurses, physical therapists, occupational therapists, social workers and psychologists were surveyed to identify problems in functioning and contextual factors of individuals with TBI using open-ended questions. All answers were translated (“linked”) to the ICF based on established rules. The frequencies of the linked ICF categories were reported stratified based on context. Results: One-hundred thirty seven professionals from the six World Health Organization regions identified 5656 concepts. 92.66% could be linked to the ICF; 33.03% were related to the domain of body functions, 27.28% to activities and participation, 10.98% to structures and 21.38% to environmental factors. Conclusions: The complexity of TBI was described through the identification of a wide variety of ICF categories. ICF language proved to be a neutral framework allowing the comparison of answers between different professionals in different world regions. Implications for Rehabilitation People that suffered a traumatic brain injury (TBI) may have a variety of sequelae that impair functioning. The International Classification of Functioning, Disability and Health (ICF) can help in providing information regarding the identification of patients problems and needs as well as planning, implementing and coordinating the rehabilitation process. The ICF provides a frame of reference process illustrated as the rehabilitation cycle that can help during the rehabilitation process in goal setting bringing together the clinicians’ and patient’s perspectives in a patient oriented biopsychosocial approach. In the field of TBI rehabilitation, activity limitations and participation restrictions are broadly affected as reported by the professionals interviewed and highly influenced by cognitive and moreover behavioral problems.

Behavioral scales used in severe and moderate traumatic brain injury

UNLABELLED Neurobehavioral disorders are common consequences of traumatic brain injury (TBI) that should be objectively assessed in this population. The use of scales allows us to unify terms both in clinical practice and investigative work; it also constitutes a useful guide in clinical interviews and makes it possible to see outcome changes in patients with or without intervention. The aim of this study is to review the most frequently neurobehavioral scales used to measure the non-cognitive disorders of conduct in TBI patients. METHOD A systematic and descriptive literature review was done in Medline, without time limit, which focused on scales applied to behavioral disorders in moderate and severe TBI patients. RESULTS Ninety articles were selected for the final review and thirty-seven different scales were identified. Seven of these instruments represent sixty-five percent of all behavioral scales applied in the studies collected and were selected for the present review. There are scales that are more general and include a wide range of neurobehavioral symptoms, like the Neurobehavioral Rating Scale and the Neuropsychiatric Inventory. On the opposite, there are questionnaires that focus on specific symptoms like aggressiveness, agitation and apathy such as the Agitated Behavior Scale or the Apathy Evaluation Scale. The forms for caregiver or staff were the most prevalent in our review. The most representative behavioral scales applied to moderate and severe TBI patients were analyzed using clinical useful, covered domains, item descriptions, administration procedures and psychometric properties.

tDCS does not enhance the effects of robot-assisted gait training in patients with subacute stroke

BACKGROUND Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique, which can modulate cortical excitability and combined with rehabilitation therapies may improve motor recovery after stroke. OBJECTIVE Our aim was to study the feasibility of a 4-week robotic gait training protocol combined with tDCS, and to study tDCS to the leg versus hand motor cortex or sham to improve walking ability in patients after a subacute stroke. METHODS Forty-nine subacute stroke patients underwent 20 daily sessions (5 days a week for 4 weeks) of robotic gait training combined with tDCS. Patients were assigned either to the tDCSleg group (n = 9), receiving 2 mA anodal tDCS over the motor cortex leg representation (vertex), or an active control group (n = 17) receiving anodal tDCS over the hand motor cortex area (tDCShand). In addition, we studied 23 matched patients in a control group receiving gait training without tDCS (notDCS). Study outcomes included gait speed (10-meter walking test), and quality of gait, using the Functional Ambulatory Category (FAC) before and after the 4-week training period. RESULTS Only one patient did not complete the treatment because he presented a minor side-effect. Patients in all three groups showed a significantly improvement in gait speed and FAC. The tDCSleg group did not perform better than the tDCShand or notDCS group. CONCLUSION Combined tDCS and robotic training is a safe and feasible procedure in subacute stroke patients. However, adding tDCS to robot-assisted gait training shows no benefit over robotic gait training alone.

Olfactory function in an excitotoxic model for secondary neuronal degeneration: Role of dopaminergic interneurons

Secondary neuronal degeneration (SND) occurring in Traumatic brain injury (TBI) consists in downstream destructive events affecting cells that were not or only marginally affected by the initial wound, further increasing the effects of the primary injury. Glutamate excitotoxicity is hypothesized to play an important role in SND. TBI is a common cause of olfactory dysfunction that may be spontaneous and partially recovered. The role of the glutamate excitotoxicity in the TBI-induced olfactory dysfunction is still unknown. We investigated the effects of excitotoxicity induced by bilateral N-Methyl-D-Aspartate (NMDA) OB administration in the olfactory function, OB volumes, and subventricular zone (SVZ) and OB neurogenesis in rats. NMDA OB administration induced a decrease in the number of correct choices in the olfactory discrimination tests one week after lesions (p<0.01), and a spontaneous recovery of the olfactory deficit two weeks after lesions (p<0.05). A lack of correlation between OB volumes and olfactory function was observed. An increase in SVZ neurogenesis (Ki67+ cells, PSANCAM+ cells (p<0.01) associated with an increase in OB glomerular dopaminergic immunostaining (p<0.05) were related to olfactory function recovery. The present results show that changes in OB volumes cannot explain the recovery of the olfactory function and suggest a relevant role for dopaminergic OB interneurons in the pathophysiology of recovery of loss of smell in TBI.