T. M. McMillan

Disability in young people and adults after head injury: 12–14 year follow-up of a prospective cohort

Background There is a need to establish how long term outcome evolves after head injury (HI) and factors related to this, to inform opportunities for intervention. Objective To determine late outcome in adults 12–14 years after hospital admission for HI and to examine relationships between injury, early and late factors, and disability. Methods A prospective cohort with HI, whose outcome was reported previously at 1 and 5–7 years after injury, were followed up after 12–14 years. Participants were assessed using structured and validated measures of disability (Glasgow Outcome Scale-Extended), psychological well being, alcohol use and health status. Results Of 219 survivors followed-up at 5–7 years, 34 (15.5%) had died by 12–14 years. Disability remained common in survivors at 12–14 years (51%), as found at 1 and 5–7 years (53%). For those disabled at 1 year, outcome was poor, with 80% dead or disabled at 12–14 years. Older age at injury, a premorbid history of brain illness or physical disability and post-injury low self-esteem and stress were associated with disability at 12–14 years. Disability changed between 5–7 and 12–14 years in 55% of survivors, improving in 23%. Late changes in disability between 5–7 and 12–14 years were associated with self-perceptions of locus of control as being ‘powerful others’ at 5–7 years. Conclusions Disability is common 12–14 years after hospital admission with a HI. For some there is a dynamic process of change in disability over time that is associated with self-perceptions of control that could be a target for intervention based research.

Neuropsychological deficits and opiate abuse

Cognitive functioning was examined in people with a current or past history of opiate abuse using a range of neuropsychological tests. Sixty percent of those currently abusing opiates showed impairments of at least two standard deviations from the published norms on two or more neuropsychological tests, a significantly higher incidence than found in matched controls with no history of drug abuse. The drug free group of recovering addicts fell between the other groups without significant differences. It was concluded that the risk of neuropsychological impairment is greater in opiate abusers, and that recovery may occur during abstinence.

Rehabilitation of unilateral neglect : Improving function by contralesional limb activation

Unilateral neglect predicts poor motor recovery following right hemisphere stroke. Contralesional limb activation has previously been shown to reduce neglect of the left side of space (Robertson & North, 1992), and it is proposed that this happens in part due to overcoming inhibition from competitor perceptuomotor circuits in the undamaged lefthemisphere. Application of this principle to clinical rehabilitation results in improvements in neglect and in everyday function (Robertson, North, & Geggie, 1992). The present study extends and replicates this finding with a case of severe unilateral neglect, whose statistically significant improvement in measured neglect is confined to near peripersonal space, and not to personal space nor far peripersonal space. The theoretical implications of this finding for understanding recovery from unilateral neglect are discussed.

Rehabilitation by limb activation training reduces left-sided motor impairment in unilateral neglect patients: A single-blind randomised control trial

Limb activation treatment for unilateral neglect has been shown to be effective in several single case studies (Robertson, Hogg, & McMillan, 1998a; Robertson, North, & Geggie, 1992). Limb Activation Treatment (LAT) is based on the theoretical model that links different aspects of spatial representation in the brain. Specifically, proprioceptive representations are strongly linked to external visual representations, such as activation of one may have influences on the other. LAT is implemented using an automatic device—the limb activation device (LAD). This device encourages patients with left unilateral neglect to make small movements with the partly paralysed left side of their body. Thirty-nine patients with right brain damage following cerebrovascular accident (CVA) who showed left unilateral neglect, were randomly allocated to perceptual training plus LAT or to perceptual training alone. Both groups received training of 12 sessions of 45 min duration over a 12 week period; 36 of the 39 patients were successfully followed up blind at 3 months, a total of 32 were followed up blind at 6 months and 26 at 18–24 months. Outcome was assessed using a variety of standardised functional outcome and neuropsychological measures. LAT treatment was associated with significantly improved left-sided motor function, with effects lasting up to 18–24 months. The limb activation device can be used in the context of existing therapy with no additional therapy time. This study shows that LAT can produce enduring improvements in left-sided motor impairment in CVA patients suffering left unilateral neglect.

Brief mindfulness training for attentional problems after traumatic brain injury: A randomised control treatment trial

A mindfulness meditation technique has been shown to be effective in reducing self-reports of pain and mood disorder in chronic pain patients. Although a pilot study on traumatic brain injury patients showed improvement in self-report of cognitive impairment, a larger scale randomised control treatment trial found no differences on objective or self-report measures of cognitive function, mood or symptom reporting. Brief exposure to mindfulness meditation cannot be recommended as a treatment technique for traumatic brain injury cases.

Quality of life in children with acquired brain injury: Parent perspectives 1–5 years after injury

Primary objective: To obtain parental ratings of childrens quality of life, cognitive, emotional and behavioural functioning, as well as ratings of service provision, following traumatic brain injury (TBI). Research design: A retrospective, cross-sectional study. Methods and procedures: Parents of 47 children with mild or moderate–severe TBI completed standardized questionnaires evaluating quality of life (PedsQL 4.0) and cognitive, emotional and behavioural functioning (Strengths and Difficulties Questionnaire). Data collected was compared with published normative data for these scales. Views regarding parental experiences of care and their ratings of service provision were also obtained. Results: Quality of life was significantly lower in 13-times as many children with TBI than expected from the normative population. Parents reported that more than 43% of children with TBI had cognitive, emotional and behavioural difficulties that impacted on their daily life. Whilst high levels of social deprivation were found, this did not fully explain the significantly raised levels of difficulties. Another factor associated with this poor outcome was the absence of systematic, routine follow-up or intervention. Conclusions: Parents frequently reported poor quality of life and cognitive, emotional and behavioural problems in their children following TBI. These preliminary findings indicate that children, after TBI, are at risk of developing persistent clinical problems and require follow-up beyond the acute period of their recovery.

Post-traumatic stress disorder and traumatic brain injury: A review of causal mechanisms, assessment,and treatment

In this paper we explore the evidence for post-traumatic stress disorder (PTSD) after traumatic brain injury (TBI). We examine its possible mediating mechanisms after brain injury, the evidence for its occurrence, risk, and protective factors, and the implications for intervention and service demands. In the first section we review the current literature relevant to cause, maintenance, and treatment of PTSD in general, before addressing issues associated with the assessment and management of PTSD after TBI. It is argued that PTSD may occur after a brain injury, and can be, relatively, a common disorder. However, explanatory mechanisms for its occurrence may be speculative. In this context, we argue, assessment and treatment need to be carefully considered, and comprehensive.

A systematic review of psychological interventions to alleviate cognitive and psychosocial problems in children with acquired brain injury

Aim  It is now generally accepted that paediatric acquired brain injury (ABI) can have an impact on a child’s cognitive, social, and behavioural functioning. However, the lack of guidelines on effective interventions for the affected children and their families, particularly beyond the acute recovery phase, can limit access to effective support. We provide a systematic review of the literature on the effectiveness of psychological interventions aimed at alleviating cognitive and psychosocial outcomes after paediatric ABI.

Errors in diagnosing post-traumatic stress disorder after traumatic brain injury

Evidence to support the view that post-traumatic stress disorder (PTSD) can occur after traumatic brain injury (TBI) continues to grow. However, the reported incidence of cases with both diagnoses ranges widely, from less than 1% to more than 50%. Given that the incidence of TBI is high, a more precise incidence has to be established if screening and treatment resources are to be considered. Are cases being missed or are they over-diagnosed? The single case report presented here does not definitively answer this question, but illustrates the potential shortcomings of diagnosing PTSD using questionnaire measures alone (Impact of Events Scale, Post-traumatic Stress Diagnostic Scale and General Health Questionnaire) and indicates a need for a conjoint interview which takes into account the common effects of TBI and the symptom overlap between PTSD and TBI.

Further recovery in a potential treatment withdrawal case 10 years after brain injury

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7–10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.