Traumatic brain injury: Implications for practice

This article presents a brief overview of the prevalence and history of traumatic brain injury (TBI), discusses the multidimensional effects of TBI, describes the current focus of TBI rehabilitation, and summarizes outcomes from (re)habilitation work with individuals with traumatic brain injury. The importance of this critical area to rehabilitation personnel is discussed, along with suggestions for future research and evaluation studies.     

Family response to traumatic brain injury

The stress experienced by families with a member who has experienced a traumatic brain injury (TBI) has recently been addressed in the counselling and rehabilitation literature. Given that rehabilitation centres have physical restoration of the patient as a primary mandate, the emotional and social adjustment needs of family members are often overlooked. Information on TBI and its effect on families will help counsellors and psychologists contribute to the family adjustment process.     

Long-term ability to interpret facial expression after traumatic brain injury and its relation to social integration

There is considerable evidence that individuals with traumatic brain injury (TBI) experience problems interpreting the emotional state of others. However, the functional implications of these changes have not been fully investigated. A study of 13 individuals with severe TBI and an equal number of matched controls found that TBI participants had significantly more difficulty interpreting facial expression and matching emotions to social situations. A significant relationship was also established between social integration and ability to interpret facial expression for TBI participants. These results support the inclusion of therapy targeting this area within rehabilitation programs for individuals with TBI.     

Women's experience of brain injury: An interpretative phenomenological analysis

Acquired traumatic brain injury (TBI) can leave the survivor with a complex range of psychological sequalae. This study aims to investigate the experience from the perspective of women with acquired TBI. Using a qualitative research method, six women with a TBI were interviewed about their experience, and the interviews were transcribed verbatim and analysed according to Interpretative Phenomenological Analysis (IPA). The major themes that emerged were: awareness of change; the emotional reaction; struggling to make sense; adaptation and acceptance. This article describes the process of adaptation, and the implications for rehabilitation are discussed. It is suggested that an intervention based on these themes might be an effective tool in rehabilitation.     

Subtle Motor Findings During Recovery from Pediatric Traumatic Brain Injury: A Preliminary Report

Pediatric traumatic brain injury (TBI) is a heterogeneous condition, varying in both severity and sequelae. The long-term motor deficits following severe TBI requiring inpatient rehabilitation are better established than those following milder forms of TBI. The authors examined motor performance 2 and 12 months postinjury in children without overt motor impairment using standard measures of upper limb function and the Physical and Neurological Examination for Subtle Signs (PANESS). The PANESS was sensitive to differences between children with TBI and uninjured children as well as to changes in children with TBI over time. These data suggest that subtle motor deficits are present after milder forms of TBI and, particularly those related to balance and gait, may persist even 12 months postinjury.     

Depression After Traumatic Brain Injury: A Review of Evidence for Clinical Heterogeneity

Depression represents a major source of disability among individuals who have suffered a traumatic brain injury (TBI), with estimates of prevalence in this population ranging over 50%. In comparison with other sequelae of TBI, depression is often poorly conceptualized and treated among acute care and rehabilitation professionals. One reason for this is the lack of clear etiological models for the development of depression following TBI. This paper argues that post-TBI depression actually represents a heterogeneous category, with multiple etiologic pathways and clinical implications. The literature in this area is reviewed, with an emphasis on an appreciation of the diversity within this clinical population. Conclusions focus on suggestions for differential diagnosis and treatment options.     

Traumatic Brain Injury Outcome in Older Adults: A Critical Review of the Literature

This paper is a critical overview of the literature on older adults' outcome after traumatic brain injury (TBI). Eighteen outcome studies were reviewed. Results indicated that older patients demonstrated an increased risk for negative outcome following TBI when compared to younger patients with similar injury severity. Poorer outcome was characterized by higher mortality rates, decreased likelihood of returning to preinjury living arrangement, and declines in cognitive and affective functioning. In the studies reviewed, discharge destination, global outcome scales, and standardized neuropsychological tests were the primary measures of outcome from elderly TBI. Conceptual and methodological difficulties including variability in the definition of and inadequate measures of recovery from elderly TBI, inadequate control groups, and poor follow-up were discussed. Recommendations for future outcome research to increase uniformity in defining recovery in order to enhance comparability between studies and to tailor cognitive rehabilitation to the special needs of the older TBI patient were provided.     

Temporal stability of the Wisconsin Card Sorting Test in a chronic traumatic brain injury sample

The aim of the present study was to investigate the temporal stability of the Wisconsin Card Sorting Test (WCST) in a clinical population with documented brain pathology, stable cognitive deficits, and for whom repeated testing is common: chronic severe traumatic brain injury (TBI). Participants were 34 patients at least 1 year post severe TBI living at a large residential rehabilitation facility. The WCST was administered in standard fashion with both the standard and 64-card versions scored. All derived scores with norms were examined. Results indicated acceptable temporal stability of most scores for both the standard and short WCST, although the stability of the WCST-64 was poorer than for the standard WCST. Three sets of significant change indices are provided for clinical use.     

Recovery in memory function, and its relationship to academic success, at 24 months following pediatric TBI.

While a number of research papers have reported findings on memory deficits following traumatic brain injury (TBI), only limited studies have monitored the recovery of these skills over time. The present study examined memory ability and its effect on academic success in a group of children who had sustained a mild, moderate, or severe traumatic brain injury (TBI). Results showed that the severe TBI group exhibited greater deficits on memory tasks, irrespective of modality, in the acute, 6-, 12-, and 24-month postinjury stages, in comparison to mild and moderate TBI groups. Performance on academic measures was dependent on both injury severity and task demands. Preinjury academic ability and verbal memory indices best predicted academic success.     

Recovery in Memory Function,and its Relationship to Academic Success,at 24 Months Following Pediatric TBI*

While a number of research papers have reported findings on memory deficits following traumatic brain injury (TBI), only limited studies have monitored the recovery of these skills over time. The present study examined memory ability and its effect on academic success in a group of children who had sustained a mild, moderate, or severe traumatic brain injury (TBI). Results showed that the severe TBI group exhibited greater deficits on memory tasks, irrespective of modality, in the acute, 6-, 12-, and 24-month postinjury stages, in comparison to mild and moderate TBI groups. Performance on academic measures was dependent on both injury severity and task demands. Preinjury academic ability and verbal memory indices best predicted academic success.     

Emerging narrative discourse skills 18 months after traumatic brain injury in early childhood

This study examined the longer term effect of traumatic brain injury (TBI), approximately 18 months post-injury, on emerging narrative discourse skills of 85 children with orthopaedic injury (OI), 43 children with moderate TBI, and 19 children with severe TBI who were between 3 years and 6 years 11 months at injury. Children with TBI performed worse than children with OI on most discourse indices. Children with severe TBI were less proficient than children with moderate TBI at identifying unimportant story information. Age and pragmatic skills were predictors of discourse performance.     

A Multidimensional Approach to Apathy after Traumatic Brain Injury

Apathy is commonly described following traumatic brain injury (TBI) and is associated with serious consequences, notably for patients’ participation in rehabilitation, family life and later social reintegration. There is strong evidence in the literature of the multidimensional nature of apathy (behavioural, cognitive and emotional), but the processes underlying each dimension are still unclear. The purpose of this article is first, to provide a critical review of the current definitions and instruments used to measure apathy in neurological and psychiatric disorders, and second, to review the prevalence, characteristics, neuroanatomical correlates, relationships with other neurobehavioural disorders and mechanisms of apathy in the TBI population. In this context, we propose a new multidimensional framework that takes into account the various mechanisms at play in the facets of apathy, including not only cognitive factors, especially executive, but also affective factors (e.g., negative mood), motivational variables (e.g., anticipatory pleasure) and aspects related to personal identity (e.g., self-esteem). Future investigations that consider these various factors will help improve the understanding of apathy. This theoretical framework opens up relevant prospects for better clinical assessment and rehabilitation of these frequently described motivational disorders in patients with brain injury.     

Attentional Skills in the Acute Phase Following Pediatric Traumatic Brain Injury

Only a limited number of studies have investigated attention following pediatric head-injury. The present study examined sustained attention and processing speed in a group of children who had sustained a mild (n = 27), moderate (n = 33) or severe (n = 16) traumatic brain injury (TBI). No significant differences were evident between the TBI groups on reaction time measures. Results did show that the severe TBI group exhibited greater deficits in the area of sustained attention, in comparison to children with mild and moderate injuries, in the acute stage following traumatic brain injury. This difficulty may impact on the future development of skills dependent on intact attentional capacity.     

Attentional skills in the acute phase following pediatric traumatic brain injury.

Only a limited number of studies have investigated attention following pediatric head-injury. The present study examined sustained attention and processing speed in a group of children who had sustained a mild (n = 27), moderate (n = 33) or severe (n = 16) traumatic brain injury (TBI). No significant differences were evident between the TBI groups on reaction time measures. Results did show that the severe TBI group exhibited greater deficits in the area of sustained attention, in comparison to children with mild and moderate injuries, in the acute stage following traumatic brain injury. This difficulty may impact on the future development of skills dependent on intact attentional capacity.     

A review of social disinhibition after traumatic brain injury

Acquired social disinhibition refers to a debilitating behavioural syndrome commonly reported after a severe traumatic brain injury (TBI) and is characterized by inappropriate social behaviour, often described as immaturity and insensitivity towards others. These behaviours can have enduring effects on the social capability of the individual and their relationships with others. However, research into socially disinhibited behaviour after TBI has been thwarted by a lack of consensus in the literature on definition and measurement. This review provides an overview of our current understanding of the definition, measurement, prevalence, associated outcomes, neuropathology, and underlying mechanisms of social disinhibition after TBI. In addition, suggestions are made for future research to further our understanding of this syndrome with the eventual aim of rehabilitating problematic behaviours. It is concluded that an improved understanding of what causes disinhibited behaviour after TBI will be necessary for the development of effective treatment strategies aimed at the rehabilitation of underlying impairments.     

California verbal learning test indicators of Malingered Neurocognitive Dysfunction: sensitivity and specificity in traumatic brain injury

The present study used well-defined traumatic brain injury (TBI) and mixed neurological (other than TBI) and psychiatric samples to examine the specificity and sensitivity to Malingered Neurocognitive Dysfunction (MND) of four individual California Verbal Learning Test (CVLT) variables and eight composite CVLT malingering indicators. Participants were 275 traumatic brain injury and 352 general clinical patients seen for neuropsychological evaluation. The TBI patients were assigned to one of five groups using the Slick, Sherman, and Iverson (1999) criteria: no incentive, incentive only, suspect, and malingering (both Probable MND and Definite MND). Within TBI, persons with the strongest evidence for malingering (Probable and Definite) had the most extreme scores. Good sensitivity (approximately 50%) in the context of excellent specificity (> 95%) was found in the TBI samples. Issues related to the appropriate clinical application of these data are discussed.     

The clinical utility of the Rey Auditory-Verbal Learning Test in medical rehabilitation

Recent research has reported the Rey Auditory-Verbal Learning Test Trial V (RAVLT-V) score to be a sensitive indicator of global cognitive functioning, not merely verbal learning skills. The concurrent validity of the RAVLT-V relative to other neuropsychological measures frequently utilized in medical rehabilitation was investigated in a sample of 64 outpatients diagnosed with traumatic brain injury (TBI). The sample was predominantly male (77%), white (97%), youthful (31.4±11.5 years), high school educated, and an average of 53 months postinjury. Using stepwise multiple regression analysis, a three-variable model consisting of gender, Wechsler Memory Scale-Revised Delayed Memory Index, and Trailmaking Part B (time) accounted for 61% of the variance in RAVLT-V scores. These findings suggest that in TBI patients, the RAVLT taps not only specific verbal learning and memory, but also global cognitive functions. Sensitivity to diffuse neuropsychological changes and ease/speed of administration make the RAVLT a valuable tool in medical rehabilitation settings.     

Fornix and hippocampal atrophy in traumatic brain injury

This study compared a fornix cross-sectional-area measurement and hippocampal volume in 86 traumatic brain injury (TBI) subjects with 46 normal controls. The TBI group showed a significant reduction in fornix area and hippocampal volume. It was also shown that initial injury severity was related to the degree of atrophy in both structures. Although fornix size and hippocampal volume correlated, such a modest correlation between these two structures suggests differential and potentially independent mechanisms of injury. The General Memory Index score from the Wechsler Memory Scale-Revised was shown to be significantly correlated with hippocampal volume following TBI.     

Attention After Pediatric Traumatic Brain Injury: A Multidimensional Assessment

Attentional disturbance is a common complaint after TBI in children and adolescents, however, few studies have assessed post-traumatic attentional functions. The attentional constructs proposed by Mirsky, Anthony, Duncan, Ahearn, and Kellam (1991) provided a multidimensional framework for prospective assessment of late attentional disturbance after mild-moderate (n = 34) and severe (n = 57) traumatic brain injury (TBI). Attention was evaluated from 5 to 8 years after TBI in children ages 0 to 15 years at the time of injury. Children with severe TBI performed more poorly than children with mild-moderate TBI on tests comprising the focus/execute and shift constructs. Younger children scored below older children irrespective of injury severity on the Digit Span subtest and interstimulus interval scores from an adaptive rate continuous performance test reflecting the encode and sustain constructs of Mirsky et al. (1991). Age × Severity interaction effects were found for speeded perceptual-motor tests; scores were reduced following mild-moderate and severe TBI in younger children and following severe TBI in older patients. Results are discussed in terms of the vulnerability of skills in a rapid stage of development to disruption by acquired brain injury.     

Attention and Communication Following TBI: Making the Connection through a Meta-Narrative Systematic Review

Neuropsychology Review - Background and aim: Communication difficulties are one of the hallmark characteristics of adults following traumatic brain injury (TBI), a difficulty that incorporates...