Measuring QoL with SF-36 in Older Americans with TBI

This study demonstrated reliability and factor structure of the Medical Outcomes Study Short-Form Health Survey (SF-36) among older Americans with Traumatic brain injury (TBI), and evaluated effects of injury severity and race on SF-36's items and latent domains. A representative sample of 654 older, racially diverse patients with TBI was selected from the South Carolina Traumatic Brain Injury Follow-up Registry. Reliability and factor structure of SF-36 were evaluated using Cronbach’s alpha and confirmatory factor analysis (CFA). Multiple-indicator multiple-causes (MIMIC) models were used to study effects of injury severity and race on items (differential item functioning, DIF) and latent domains (population heterogeneity) of SF-36. SF-36 was reliable and its current eightfactor structure was confirmed. While TBI severity did not impact latent domain scores of SF-36, race did. Blacks had higher vitality and lower role-emotional scores than whites. The measurement model was invariant to injury severity and race (free of DIF), and DIF did not contribute to the differences of vitality and role-emotional between black and white older TBI patients. SF-36 was valid to measure quality of life (OoL) after TBI in racially diverse elderly population. Blacks tend to assert to strong coping behaviors in the presence of physical stress while admitting low performance due to emotional stress. In QoL research where the primary outcomes are usually composite scores from instruments, MIMIC models have advantages over conventional multivariable regression models in testing the validity of the instruments and assessing covariate effects on latent traits of instruments while controlling for DIF effects.     

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.     

Impairment and recovery in inhibitory control after traumatic brain injury in children: effect of age at injury, injury severity and lesion location

We examined the effect of traumatic brain injury (TBI) on inhibitory control, trajectories of recovery of inhibitory control, and the effect of age at injury, severity, and lesion location on recovery. Participants were 127 children with TBI aged 5-16 years and 117 controls of similar age.Latency of response inhibition was measured with the stop signal task within 1 month of the injury and again at 3, 6, 12, and 24 months.Performance of children with TBI was compared with that of controls.Growth curve analyses showed impairments in response inhibition postinjury.Compared with controls, TBI children improved over time in response inhibition. Younger TBI children recovered better on response inhibition than older TBI children. No significant effect of severity or right frontal lesion on recovery of response inhibition was found. TBI has an acute effect on inhibitory control but which recovers over time.     

Resilience and Other Possible Outcomes After Mild Traumatic Brain Injury: a Systematic Review

The relation between resilience and mild traumatic brain injury (TBI) outcome has been theorized but empirical studies have been scarce. This systematic review aimed to describe the research in this area. Electronic databases (Medline, CINAHL, PsychINFO, SPORTdiscus, and PILOTS) were searched from inception to August 2015 for studies in which resilience was measured following TBI. The search terms included ‘TBI’ ‘concussion’ ‘postconcussion’ ‘resilience’ and ‘hardiness’. Inclusion criteria were peer reviewed original research reports published in English, human participants aged 18 years and over with brain injury, and an accepted definition of mild TBI. Hand searching of identified articles was also undertaken. Of the 71 studies identified, five studies were accepted for review. These studies were formally assessed for risk of bias by two independent reviewers. Each study carried a risk of bias, most commonly a detection bias, but none were excluded on this basis. A narrative interpretation of the findings was used because the studies reflected fundamental differences in the conceptualization of resilience. No studies employed a trajectory based approach to measure a resilient outcome. In most cases, the eligible studies assessed trait resilience with a scale and used it as a predictor of outcome (postconcussion symptoms). Three of these studies showed that greater trait resilience was associated with better mild TBI outcomes (fewer symptoms). Future research of the adult mild TBI response that predicts a resilient outcome is encouraged. These studies could yield empirical evidence for a resilient, and other possible mild TBI outcomes.     

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.     

Neuropathological determinants of acquired attention disorders in traumatic brain injury

Attentional disorders are frequently mentioned neuropsychological sequalae following traumatic brain injury (TBI). However, little is known about the recovery of attention, or the determinants of variability of attentional functioning following TBI. The present study was undertaken to examine (1) the extent to which attentional disorders are present among patients at various chronicity stages following TBI, (2) differences in performance on a number of measures of attention as a function of different clinical-neuropathological syndromes. A sample of 70 TBI subjects were rated according to different clinical-neuropathological syndromes and neuropsychologically evaluated. The results suggest that TBI patients of different chronicity stages, with significantly different lengths of coma, did not significantly differ in terms of the type or severity of attentional disorders. However, when the same patients were classified according to clinical-neuropathological syndromes, significant differences in the severity and type of attentional disorders were evident. The findings were interpreted to suggest that typical indices of severity of TBI do not correlate with the severity and type of attentional disorders and that qualitative aspects of the subjects' pathology may be more important in determining the nature of the attentional disorders.     

Executive function outcomes of children with traumatic brain injury sustained before three years

Traumatic brain injury (TBI) is a common cause of disability in childhood. While the outcomes of TBI sustained in school years has been heavily researched, very little is known about the impact of TBI in infants and young children. The aim of this study was to investigate the impact of TBI on executive function (EF) in children who sustained a TBI before 3 years of age. A group of 55 children, 19 with a mild TBI, 16 children with a moderate-severe TBI, and 20 uninjured comparison children participated. The EF of children aged 3 to 6 years were compared using child-based measures of attentional control and information processing. Parents completed questionnaires rating their child's EF. Severity groups differed on the child-based EF measure of attentional control with children with TBI performing below the control group. There were no significant group differences for information processing or parent-rated EF. It appears that children who sustain a TBI before the age of 3 years display impairments in some areas of attentional control 3–4 years postinjury. The findings fit with the existing EF literature for older children.     

Is there a trade-off between cognitive and motor recovery after traumatic brain injury due to competition for limited neural resources?

The status of neurorehabilitation for traumatic brain injury (TBI) is under active debate because of a dearth of research findings demonstrating effectiveness. This may be due, in part, to limitations in our understanding of basic mechanisms of cognitive and motor recovery,including those that might impede recovery. In this regard, we examined whether overall recovery following TBI might be undermined by competition between cognitive and motor functions for finite neural resources during recovery. In this preliminary study, 21 moderately and severely impaired patients were administered cognitive and motor assessments at 1, 4, and 12 months post-TBI, and recovery of cognitive and motor functions was measured using regression residuals. Negative correlations between recovery of cognitive versus motor functions were used as the index of competition. We found suggestive evidence that there may indeed be a trade-off between the recovery of cognitive and motor functions after TBI. Implications for rehabilitation are discussed.     

Depression and cognitive sequelae registered within the first year among young Danish TBI survivors

The aim of the study was to determine the proportion of depression and cognitive sequelae among young (15-30 years) Danish TBI survivors referred to interdisciplinary evaluation through a nationwide government-initiated health initiative. The cross-sectional study is based on data from the “Danish register for young adults with acquired brain injury” on TBI survivors included from October 2013 to December 2016. The main measures were Major depression inventory, Trail making test A and B, Fluency, Word learning with selective reminding, Matrix reasoning, Coding and Glasgow outcome scale - extended (GOS-E). During the study period, 131 young TBI survivors were referred to one of five national outpatient clinics. Ninety-six had complete data and of these 14.6% fulfilled the ICD-10 diagnostic criteria for depression and 34.4% had cognitive sequelae. An association was found between depression and cognitive sequelae (p = 0.004). Patients with both depression and cognitive sequelae (n = 10) had a significantly lower mean score on GOS-E (p = 0.0001). Depression and cognitive sequelae were frequent and associated with a poorer global functional outcome among young TBI survivors referred within a year after trauma. This finding and the notion that only 20% of the expected TBI population was referred to this nationwide health initiative indicate an unacknowledged need for interdisciplinary follow-up.     

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.     

Chronic Pain and Neuropsychological Functioning

This review article examines the effect of chronic pain on neuropsychological functioning. Primary attention is given to studies that include patient groups without a history of traumatic brain injury (TBI) or neurologic disorders. Numerous studies were identified that demonstrate neuropsychological impairment in patients with chronic pain, particularly on measures assessing attentional capacity, processing speed, and psychomotor speed. Despite suggestive findings, further studies are needed to clarify the variables that mediate the impact of pain on neuropsychological functioning and the unique role of various symptoms often associated with chronic pain.     

Children's Narratives Following Traumatic Brain Injury: Linguistic Structure, Cohesion, and Thematic Recall

Narrative discourse and intellectual functioning were examined 3 years following traumatic brain injury (TBI) in children 1 to 8 years of age at the time of injury. The language-impaired TBI group (n= 9) had language deficits during the subacute stage of recovery; their performance was contrasted with that of a TBI comparison group equated on neurologic and demographic variables that did not show subacute language impairment (n= 8) and a sibling comparison group (n= 9). The language-impaired TBI group had lower Verbal and Full-Scale IQ scores and produced fewer words and utterances than the sibling group on a story retelling task; their stories were characterized by fewer complete referential and lexical ties and more referential errors, indicating difficulty conjoining meaning across sentences. The language-impaired TBI group recalled approximately one-third of the propositions needed to maintain the story theme and made more errors sequencing the propositions than either the TBI or the sibling comparison groups. Group differences were not obtained on the Performance IQ scores or on measures of rate or fluency of speech production, mazes, use of conjunctives, or naming errors. The discourse deficiencies of children with TBI and acute language impairment were most pronounced at the level of cognitive organization of the text reflecting text macrostructure and were least apparent at the level of lexical and sentential organization reflecting text microstructure. Results are discussed in terms of the vulnerability of developing language abilities to disruption by brain injury.     

Comparison of measured and estimated cognitive ability in older adolescents with and without ADHD

Premorbid intellectual function estimation is a crucial part of patient evaluation following a traumatic brain injury (TBI), especially in individuals with ADHD who are at higher risk for TBI compared to their non-ADHD peers. This study investigates the value of using regression-based estimates of intelligence for concurrently predicting measured intelligence in a sample of older adolescents with and without a childhood history of ADHD. Correlations between measured and estimated intelligence are highly significant in the full sample and in the individual groups. Adding reading performance to the regression equation increases the accounted-for variance in both groups. Results indicate that regression equations based on demographic characteristics constitute a valid method for estimating premorbid functioning in adolescents with ADHD and that they can play an essential role in the assessment of individuals with ADHD who sustain TBI, especially when measures of word reading are used to augment demographic estimates.     

Cognitive Sequelae of Blast-Induced Traumatic Brain Injury: Recovery and Rehabilitation

Blast-related traumatic brain injury (bTBI) poses a significant concern for military personnel engaged in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Given the highly stressful context in which such injury occurs, psychiatric comorbidities are common. This paper provides an overview of mild bTBI and discusses the cognitive sequelae and course of recovery typical of mild TBI (mTBI). Complicating factors that arise in the context of co-morbid posttraumatic stress disorder (PTSD) are considered with regard to diagnosis and treatment. Relatively few studies have evaluated the efficacy of cognitive rehabilitation in civilian mTBI, but we discuss cognitive training approaches that hold promise for addressing mild impairments in executive function and memory, akin to those seen in OEF/OIF veterans with bTBI and PTSD. Further research is needed to address the patient and environmental characteristics associated with optimal treatment outcome.     

Early Versus Late Onset of Spinal Cord Injury Among the Elderly

The objective of this study is to compare elderly individuals with late (60 years old) versus early (<60 years old) onset spinal cord injury (SCI) across quality of life (QOL) domains for which cross-sectional design was used. The outcome measures selected were secondary medical complications (e.g., pneumonia, autonomic dysreflexia, number of days hospitalized), Functional Independence Measure (FIM), Satisfaction With Life Scale (SWLS), and the Craig Handicap Assessment and Reporting Technique (CHART). Analyses between groups showed that individuals with SCI onset 60 years of age or older were significantly older, had a greater proportion of incomplete lesions, were more likely to have SCI resulting from medical complication, and were less likely to be working. After controlling for differences in demographic and lesion characteristics, the majority of QOL domains were similar between groups. However, overall self-reported handicap (CHART-total score) was significantly greater among elderly with late onset SCI, particularly in the areas of physical independence and social integration. Differences in QOL between elderly with late versus early onset SCI were most prominent in the area of physical independence and social integration. The importance of appropriate statistical control, theoretical implications, and future directions are discussed.     

Working memory outcomes following traumatic brain injury in children: A systematic review with meta-analysis

The aim of this review is to systematically examine the literature concerning multicomponent working memory (WM)—comprising a central executive (CE), two storage components (phonological loop, PL and visuo-spatial sketchpad, VSSP), and episodic buffer (EB)—in pediatric traumatic brain injury (TBI). Electronic searches were conducted of MEDLINE, PsychINFO and EMBASE up to October 2014 with the inclusion criteria of children and adolescents with TBI, and quantitative methods to assess at least one component of WM. Meta-analytic procedures calculated pooled effect sizes for WM outcomes. Of the studies examined, 27 met the inclusion criteria. Children with TBI exhibited deficits in the CE and PL, but not in the VSSP, and no study could be found which examined the EB. Qualitative analysis found that greater TBI severity was associated with poorer CE functioning in five out of nine studies. Differences in patterns of brain activation were evident in four out of five fMRI studies that examined WM in TBI children and controls. Deficits in CE were associated with poorer mathematical skills in the only study that examined relations between WM and academic deficits. Notwithstanding the heterogeneity of the studies reviewed, TBI places children at risk of WM deficits. Moreover, this meta-analysis suggests that various components of WM have differential vulnerability to pediatric TBI, with significant deficits found in the CE and PL, but not in the VSSP (although the VSSP has rarely been examined to date). Future studies should be theoretically driven, employ tasks assessing all components of the WM model and examine the functional ramifications (including academic outcomes) of WM deficits in this population.     

WAIS-III factor index score patterns after traumatic brain injury

Profile subtypes, based on the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) factor index scores, were examined in a sample of 166 patients with traumatic brain injury (TBI) by means of a two-stage clustering procedure. Three reliable subtypes were found that were differentiated primarily by level of performance across all factor index scores, although each of them demonstrated a relative weakness on the Processing Speed index. These subtypes were then validated on the basis of demographic variables, injury parameters, and additional psychometric measures that had not been included in the clustering procedures. The results indicated that performance on the WAIS-III after TBI was affected by both injury severity and level of education. It is concluded that there is no unique "signature" profile on the WAIS-III after TBI, except that a relative strength on the Processing Speed index is uncommon with this condition.     

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.