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Alcohol and Drug Use Before and in the First Year After Traumatic Brain Injury: Association With Injury Severity
Brain Injury Participants: NZ4, two in a minimally conscious state (MCS), and two in a permanent vegetative state (PVS), as defined by the UK Royal College of Physicians diagnostic criteria. All participants had suffered a prior anoxic event with no other significant neurological/ psychiatric history. Interventions: Four alternating blocks of CVS and sham stimulation. Each block lasted 4weeks and comprised daily stimulation (20-40mins). Block order was counterbalanced across participants. Main Outcome Measure(s): Wessex Head Injury Matrix (WHIM) and JFK Coma Recovery Scale e Revised (CRS-R). Neuro-physiological correlates were assessed using EEG and auditory oddball ERP paradigms. Assessments were performed every two weeks. Results: As predicted, all four participants showed behavioural improvement during or immediately after CVS but not sham: participant 1 (MCS) improved by 8pts on the CRS-R, and by 38pts on the WHIM; participant 2 improved by 1pt on the CRS-R auditory subscale; participant 3 improved by 1pt on the CRS-R arousal subscale; participant 4 improved by 1pt on the CRS-R motor subscale. Changes were also apparent at the electrophysiological level. Conclusions: CVS may promote responsiveness in Low Awareness States. A larger-scale, double-blinded, dose-response study is now needed to more fully assess efficacy and safety. Key Words: neuro-modulation, brain injury, inner ear, arousal Disclosure(s): None Disclosed. Poster 215 Behavioral Changes and Depression, Disability, and Life Satisfaction in Two Cohorts of Adults With TBI Shannon B. Juengst (University of Pittsburgh), Elizabeth Skidmore, Amy Wagner Objective: To explore the association between behavior e Frontal Systems Behavioral Scale (FrSBe) e and depression, disability, and life satisfaction in two cohorts of adults with traumatic brain injury (TBI). Design: Cohort study and a cross-sectional study Setting: Community Participants: Fifty-five adults with severe TBI; Sixty-five adults with complicated mild to severe TBI. Interventions: None. Main Outcome Measure(s): Behavior was assessed with the FrSBe’s Apathy, Disinhibition, and Executive Function subscales. Depression status was determined using the Patient Health Questionnaire-9. Disability was measured in the first cohort with the Functional Independence Measure and in the second cohort with the Mayo Portland Adaptability Inventory. Life satisfaction was measured in the first cohort by Percent Back to Normal and in the second cohort by the Participation Assessment with Recombined Tools e Satisfaction. Results: Cohort 1: Apathy, disinhibition, and executive dysfunction were all significantly associated with depression (tZ-4.97 to -2.37, p<.001.022) and life satisfaction (rZ-.681 to -.332, p<.001-.016), and apathy and executive dysfunction were significantly associated with disability (rZ-.571 to -360, p<.001-.007). Cohort 2: Apathy, disinhibition, and executive dysfunction were significantly associated with disability (rZ.440-.730, p<.001-.035), regardless of time since injury, and with life satisfaction for those greater than 2 years post-injury (rZ-.803 to -391 pZ.009-.036). Conclusions: For all individuals who sustain a TBI, regardless of initial severity, behavioral changes may negatively influence depression, disability, and life satisfaction, beginning in the first year post-injury and continuing well beyond five years post-injury.Therefore, behavior may represent a viable target e both early after injury and for individuals living in the community e for rehabilitation interventions to improve various long-term outcomes after TBI. Key Words: Depression, Brain Injury, Impulsive Behavior, Apathy, Executive Function Disclosure(s): None Disclosed.
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e71 Poster 216 Examining Life Roles After Traumatic Brain Injury Using the Participation Assessment With Recombined Tools Objective Shannon B. Juengst (University of Pittsburgh), Shannon Corinne Achille, Amy Wagner, Patricia M. Arenth, Elizabeth Skidmore Objective: To define life roles after traumatic brain injury (TBI) using the Participation Assessment With Recombined Tools e Objective (PART-O) and to explore differences in depression status, satisfaction with participation, and self-efficacy by level of participation within each life role. Design: Cross-sectional study Setting: Community Participants: Sixty-five adults with history of complicated mild to severe TBI Interventions: None Main Outcome Measure(s): Life roles were assessed with the PART-O, depression status was determined by the Patient Health Questionnaire-9, satisfaction with participation was assessed with the PART-Satisfaction, and self-efficacy was assessed with the General Self-Efficacy Scale. We performed Chi-squared analyses and ANOVA to compare depression, satisfaction with participation, and self-efficacy by participation in each life role. Results: Participants were characterized as participating at low, medium, or high levels in each of eight different life roles (home-maintainer, student, worker, friend, family member, leisure, volunteer, and religious participant). Individuals participating at high levels in the role of religious participant reported greater satisfaction than those participating at low (pZ.011) or medium (pZ.048) levels.Individuals participating at high levels in the role of worker reported greater self-efficacy than those participating at low (pZ.035) or medium (pZ.020) levels. Conclusions: We established a methodology for using the PART-O to characterize level of participation in eight individual life roles.While global participation is important, understanding how participation in individual life roles influences outcomes after TBI provides more specific information about where to focus rehabilitation efforts. Identifying unique patterns of participation in life roles also allows for personalized assessment and may reveal limitations and benefits of balance across individual life roles. Key Words: Self Efficacy, Brain Injury, Depression, Community Participation, Quality of Life Disclosure(s): None Disclosed. Poster 217 Alcohol and Drug Use Before and in the First Year After Traumatic Brain Injury: Association With Injury Severity Simon Beaulieu-Bonneau (Centre interdisciplinaire de recherche en readaptation et integration sociale), Myriam Giguere, Marie-Christine Ouellet Objective: To investigate the association between injury severity and substance use before and in the first year after traumatic brain injury (TBI). Design: Prospective cohort study in the first year after TBI. Setting: Canadian level I trauma center, rehabilitation center, community. Participants: 214 adults admitted to a trauma center following TBI (50.9% mild, 49.1% moderate-severe TBI), who were interviewed 4 (nZ191), 8 (nZ154), and 12 months (nZ138) post-TBI. Interventions: Not applicable. Main Outcome Measure(s): Semi-structured interview with questions on alcohol use (yes/no; low-risk/high-risk use based on Canadian guidelines on weekly number of drinks) and drug use (yes/no). Results: The proportion of participants using alcohol significantly changed over time (p<.001), decreasing from pre-TBI (87%) to 4 months post-TBI (45%), increasing at 8 months (71%), and remaining stable at 12 months (71%). Alcohol use was significantly more common after mild than moderate-severe TBI at 4 (65% vs. 27%), 8 (83% vs. 54%), and 12 (80% vs. 59%) months (severity X time, p<.001). Similar
e72 results were found for high-risk alcohol use (time, p<.001; severity X time, pZ.022) and drug use (time, p<.001; severity X time, pZ.016). The proportion of participants using drug pre-injury was greater in moderate-severe than in mild TBI, but there was no difference in postinjury use. Conclusions: Substance use declined in the early months following TBI but increased before the end of the first year. This was especially true for alcohol use in participants with mild injury. Given that substance use may alter recovery, prevention strategies need to be reinforced, even more so for individuals not getting inpatient rehabilitation. Key Words: Alcohol Drinking, Traumatic Brain Injury, Drugs of Abuse, Substance-Related Disorders Disclosure(s): None Disclosed. Poster 218 Predictors of Post-Traumatic Amnesia Rehabilitation Outcomes Sonja Blum (NYU), Liat Rabinowitz Objective: To examine the predictive value of variables known at initial assessment of patients in post-traumatic amnesia (PTA) on outcome of acute inpatient rehabilitation. Design: Retrospective study. Setting: Acute inpatient rehabilitation at NYU medical center-Rusk Rehabilitation. Participants: Forty patients with traumatic brain injury who were in PTA at admission to acute inpatient rehabilitation (29 male, 11 female; age range 18-91; location of lesions: diffuse axonal injury 7.5% of subjects, frontal lobe 91.9%, temporal lobe 59.5%, parietal 29.7% and occipital 8.1%). Interventions: Not applicable. Main Outcome Measure(s): GOAT score, length of PTA, FIM, FAM, requirement for neuroleptics (as correlate of behavioral disturbance). Results: Initial GOAT score is predictive of length of PTA (inversely related; pZ0.031). PTA length correlated negatively with discharge FIM (pZ0.013) and FAM (pZ0.034). Almost all patients in PTA had a frontal lobe lesion. Neither initial GOAT score nor length of PTA predicted whether patients had a significant behavioral disturbance requiring neuroleptics at discharge from acute rehabilitation (14 patients discharged on neuroleptics, 25 not, data missing 1). Conclusions: A detailed examination of variables known at initial presentation to acute rehabilitation may be helpful in predicting outcomes of acute rehabilitation. Initial GOAT score may be helpful in predicting PTA length. From our small dataset we have some hints that looking at location of lesion and requirements for neuroleptics may also be helpful in prognosticating patient trajectories. Future studies on larger patient population will be needed to confirm their utility in predicting outcomes of acute rehabilitation. Key Words: traumatic brain injury, post-traumatic amnesia, frontal lobe, GOAT Disclosure(s): None disclosed. Poster 219 Self-Reports for Individuals with Severe Brain Injury Sonya Kim (Rusk Institute of Rehabilitation Medicine), Joseph F. Rath, Vance Zemon, Marie M. Cavallo, Ana Sostre, Frederick W. Foley Objective: To examine the usefulness of various self-reports of cognitive impairment in individuals with severe chronic brain injury. Design: Analysis of existing dataset. Setting: Structured day program (SDP). Participants: Fourteen individuals attending a SDP aged 23-63yrs. (MdnZ44y/IQRZ22); time-post-onset 13-40yrs. (MdnZ22.5y/ IQRZ16.5); Halstead-Reitan-Impairment Index (MdnZ1/IQRZ.10)d0.3, normal; .4, borderline; .5-1.0, impaired.
Brain Injury Interventions: Community-based activities. Main Outcome Measure(s): z-score of Problem Solving Inventory scales (PSI), approach-avoidance (AA), problem-solving confidence (PSC), personal control (PC); Raw score of Problem-Solving-Checklist (PCL, 2 indicates problem is endorsed), affective/behavioral (A/B) and cognitive (Cog) scales; Tscore of Behavioral Rating Inventory of Executive Functions InventoryeAdult version: global executive functions composite (GEC) (65, impaired). Results: PSI-AA scale was nearly -2SD below the mean. However, the remaining self-reports fell in the unimpaired range:BRIEF-A-GEC (MdnZ55.5/IQRZ31.75); PCL A/B(MdnZ .39/IQRZ.36), Cog (MdnZ .45/IQRZ.84); PSI-AA (MdnZ -1.87/IQRZ.88), PSI-PSC (MdnZ -.67/ IQRZ1.77), PSI-PC (MdnZ -.01/IQRZ.98). The PSI has been successfully usedin a number of studies where the patients using this instrument were able to demonstrate awareness and meaningfully communicate their core difficulties in solving problems (Rath et al., 2003; 2011; Heppner et al., 2004). Conclusions: These results indicate that self-report measures that ask individuals to assess their perceptions of their problem-solving could be more useful than self-reports of actual problem-solving skills, such that certain attitudes are likely more influential on the individual’s success in solving problems. Future work could use PSI-AA as an outcome measure for this population in a problem-solving-treatment study to see whether the PSI-AA score changes in accordance with improved problemsolving abilities. Key Words: Self-reports, chronic brain injury, cognition Disclosure(s): None Disclosed. Poster 220 Characteristics of Community-based Treatment For Individuals With Brain Injury Sonya Kim (Rusk Institute of Rehabilitation Medicine), Marie M. Cavallo, Vance Zemon, Joseph F. Rath, Ana Sostre, Frederick W. Foley Objective: To determine common characteristics of community-based treatment programs (CBP) for individuals with brain injury. Design: A search of peer-reviewed articles limited to the terms: community-based rehabilitation/treatment and brain injury, followed by a complementary data analysis of a CBP. Setting: Community-based structured day program. Participants: Fourteen individuals attending a CBP aged 23-63yrs (MdnZ44/IQRZ22); time-post-onset 13-40yrs (MdnZ22.5/IQRZ16.5); time enrolled in the CBP: 5mos-14.25yrs. (MdnZ5.88yrs/IQRZ7.67); Halstead-Reitan-Impairment-Index (MdnZ1, IQRZ.10)d0-.3/normal, .4/ borderline, .5-1.0/impaired. Interventions: Community-based activities. Main Outcome Measure(s): Problem Solving Inventory, approachavoidance-scale/PSI-AA; Problem Solving Checklist/PCL, 2 indicates problem is endorsed, affective/behavioral (A/B) andcognitive (Cog) scales; Satisfaction with Life Scale/SWLS, 35Zhighly satisfied to 5Zextremely dissatisfied; Rosenberg Self-esteem Scale/RSES, 10Zlow-self-esteem to 40Zhigh-self-esteem. Results: Apart from taking place outside a clinic, no consensus of what constituted “community-based treatment” emerged. In this specific CBP, all participants were determined by severity of brain injury, time-postonset, high life satisfaction, healthy self-esteem, and no complaints of impairment, except appraising their problem-solving ability as weak: SWLS (MdnZ25, IQRZ10.75), RSES (MdnZ31/IQRZ7.25), PCL-A/B (MdnZ.39/IQRZ.36), PCL-Cog (MdnZ.45/IQRZ.84); PSI-AA (MdnZ -1.87/IQRZ.88). Conclusions: Participants attended this CBP for up to 14yrs, making one characteristic of a CBP the potential lengthiness of its care. Taken together with the participants’ relatively negative self-appraisal of problem-solving ability, this characteristic could suggest a need for the reconceptualization of the meaning of “rehabilitation outcomes,” where the appropriateness of “discharge” [from treatment] is questioned.Future studies could examine
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e71 Poster 216 Examining Life Roles After Traumatic Brain Injury Using the Participation Assessment With Recombined Tools Objective Shannon B. Juengst (University of Pittsburgh), Shannon Corinne Achille, Amy Wagner, Patricia M. Arenth, Elizabeth Skidmore Objective: To define life roles after traumatic brain injury (TBI) using the Participation Assessment With Recombined Tools e Objective (PART-O) and to explore differences in depression status, satisfaction with participation, and self-efficacy by level of participation within each life role. Design: Cross-sectional study Setting: Community Participants: Sixty-five adults with history of complicated mild to severe TBI Interventions: None Main Outcome Measure(s): Life roles were assessed with the PART-O, depression status was determined by the Patient Health Questionnaire-9, satisfaction with participation was assessed with the PART-Satisfaction, and self-efficacy was assessed with the General Self-Efficacy Scale. We performed Chi-squared analyses and ANOVA to compare depression, satisfaction with participation, and self-efficacy by participation in each life role. Results: Participants were characterized as participating at low, medium, or high levels in each of eight different life roles (home-maintainer, student, worker, friend, family member, leisure, volunteer, and religious participant). Individuals participating at high levels in the role of religious participant reported greater satisfaction than those participating at low (pZ.011) or medium (pZ.048) levels.Individuals participating at high levels in the role of worker reported greater self-efficacy than those participating at low (pZ.035) or medium (pZ.020) levels. Conclusions: We established a methodology for using the PART-O to characterize level of participation in eight individual life roles.While global participation is important, understanding how participation in individual life roles influences outcomes after TBI provides more specific information about where to focus rehabilitation efforts. Identifying unique patterns of participation in life roles also allows for personalized assessment and may reveal limitations and benefits of balance across individual life roles. Key Words: Self Efficacy, Brain Injury, Depression, Community Participation, Quality of Life Disclosure(s): None Disclosed. Poster 217 Alcohol and Drug Use Before and in the First Year After Traumatic Brain Injury: Association With Injury Severity Simon Beaulieu-Bonneau (Centre interdisciplinaire de recherche en readaptation et integration sociale), Myriam Giguere, Marie-Christine Ouellet Objective: To investigate the association between injury severity and substance use before and in the first year after traumatic brain injury (TBI). Design: Prospective cohort study in the first year after TBI. Setting: Canadian level I trauma center, rehabilitation center, community. Participants: 214 adults admitted to a trauma center following TBI (50.9% mild, 49.1% moderate-severe TBI), who were interviewed 4 (nZ191), 8 (nZ154), and 12 months (nZ138) post-TBI. Interventions: Not applicable. Main Outcome Measure(s): Semi-structured interview with questions on alcohol use (yes/no; low-risk/high-risk use based on Canadian guidelines on weekly number of drinks) and drug use (yes/no). Results: The proportion of participants using alcohol significantly changed over time (p<.001), decreasing from pre-TBI (87%) to 4 months post-TBI (45%), increasing at 8 months (71%), and remaining stable at 12 months (71%). Alcohol use was significantly more common after mild than moderate-severe TBI at 4 (65% vs. 27%), 8 (83% vs. 54%), and 12 (80% vs. 59%) months (severity X time, p<.001). Similar
e72 results were found for high-risk alcohol use (time, p<.001; severity X time, pZ.022) and drug use (time, p<.001; severity X time, pZ.016). The proportion of participants using drug pre-injury was greater in moderate-severe than in mild TBI, but there was no difference in postinjury use. Conclusions: Substance use declined in the early months following TBI but increased before the end of the first year. This was especially true for alcohol use in participants with mild injury. Given that substance use may alter recovery, prevention strategies need to be reinforced, even more so for individuals not getting inpatient rehabilitation. Key Words: Alcohol Drinking, Traumatic Brain Injury, Drugs of Abuse, Substance-Related Disorders Disclosure(s): None Disclosed. Poster 218 Predictors of Post-Traumatic Amnesia Rehabilitation Outcomes Sonja Blum (NYU), Liat Rabinowitz Objective: To examine the predictive value of variables known at initial assessment of patients in post-traumatic amnesia (PTA) on outcome of acute inpatient rehabilitation. Design: Retrospective study. Setting: Acute inpatient rehabilitation at NYU medical center-Rusk Rehabilitation. Participants: Forty patients with traumatic brain injury who were in PTA at admission to acute inpatient rehabilitation (29 male, 11 female; age range 18-91; location of lesions: diffuse axonal injury 7.5% of subjects, frontal lobe 91.9%, temporal lobe 59.5%, parietal 29.7% and occipital 8.1%). Interventions: Not applicable. Main Outcome Measure(s): GOAT score, length of PTA, FIM, FAM, requirement for neuroleptics (as correlate of behavioral disturbance). Results: Initial GOAT score is predictive of length of PTA (inversely related; pZ0.031). PTA length correlated negatively with discharge FIM (pZ0.013) and FAM (pZ0.034). Almost all patients in PTA had a frontal lobe lesion. Neither initial GOAT score nor length of PTA predicted whether patients had a significant behavioral disturbance requiring neuroleptics at discharge from acute rehabilitation (14 patients discharged on neuroleptics, 25 not, data missing 1). Conclusions: A detailed examination of variables known at initial presentation to acute rehabilitation may be helpful in predicting outcomes of acute rehabilitation. Initial GOAT score may be helpful in predicting PTA length. From our small dataset we have some hints that looking at location of lesion and requirements for neuroleptics may also be helpful in prognosticating patient trajectories. Future studies on larger patient population will be needed to confirm their utility in predicting outcomes of acute rehabilitation. Key Words: traumatic brain injury, post-traumatic amnesia, frontal lobe, GOAT Disclosure(s): None disclosed. Poster 219 Self-Reports for Individuals with Severe Brain Injury Sonya Kim (Rusk Institute of Rehabilitation Medicine), Joseph F. Rath, Vance Zemon, Marie M. Cavallo, Ana Sostre, Frederick W. Foley Objective: To examine the usefulness of various self-reports of cognitive impairment in individuals with severe chronic brain injury. Design: Analysis of existing dataset. Setting: Structured day program (SDP). Participants: Fourteen individuals attending a SDP aged 23-63yrs. (MdnZ44y/IQRZ22); time-post-onset 13-40yrs. (MdnZ22.5y/ IQRZ16.5); Halstead-Reitan-Impairment Index (MdnZ1/IQRZ.10)d0.3, normal; .4, borderline; .5-1.0, impaired.
Brain Injury Interventions: Community-based activities. Main Outcome Measure(s): z-score of Problem Solving Inventory scales (PSI), approach-avoidance (AA), problem-solving confidence (PSC), personal control (PC); Raw score of Problem-Solving-Checklist (PCL, 2 indicates problem is endorsed), affective/behavioral (A/B) and cognitive (Cog) scales; Tscore of Behavioral Rating Inventory of Executive Functions InventoryeAdult version: global executive functions composite (GEC) (65, impaired). Results: PSI-AA scale was nearly -2SD below the mean. However, the remaining self-reports fell in the unimpaired range:BRIEF-A-GEC (MdnZ55.5/IQRZ31.75); PCL A/B(MdnZ .39/IQRZ.36), Cog (MdnZ .45/IQRZ.84); PSI-AA (MdnZ -1.87/IQRZ.88), PSI-PSC (MdnZ -.67/ IQRZ1.77), PSI-PC (MdnZ -.01/IQRZ.98). The PSI has been successfully usedin a number of studies where the patients using this instrument were able to demonstrate awareness and meaningfully communicate their core difficulties in solving problems (Rath et al., 2003; 2011; Heppner et al., 2004). Conclusions: These results indicate that self-report measures that ask individuals to assess their perceptions of their problem-solving could be more useful than self-reports of actual problem-solving skills, such that certain attitudes are likely more influential on the individual’s success in solving problems. Future work could use PSI-AA as an outcome measure for this population in a problem-solving-treatment study to see whether the PSI-AA score changes in accordance with improved problemsolving abilities. Key Words: Self-reports, chronic brain injury, cognition Disclosure(s): None Disclosed. Poster 220 Characteristics of Community-based Treatment For Individuals With Brain Injury Sonya Kim (Rusk Institute of Rehabilitation Medicine), Marie M. Cavallo, Vance Zemon, Joseph F. Rath, Ana Sostre, Frederick W. Foley Objective: To determine common characteristics of community-based treatment programs (CBP) for individuals with brain injury. Design: A search of peer-reviewed articles limited to the terms: community-based rehabilitation/treatment and brain injury, followed by a complementary data analysis of a CBP. Setting: Community-based structured day program. Participants: Fourteen individuals attending a CBP aged 23-63yrs (MdnZ44/IQRZ22); time-post-onset 13-40yrs (MdnZ22.5/IQRZ16.5); time enrolled in the CBP: 5mos-14.25yrs. (MdnZ5.88yrs/IQRZ7.67); Halstead-Reitan-Impairment-Index (MdnZ1, IQRZ.10)d0-.3/normal, .4/ borderline, .5-1.0/impaired. Interventions: Community-based activities. Main Outcome Measure(s): Problem Solving Inventory, approachavoidance-scale/PSI-AA; Problem Solving Checklist/PCL, 2 indicates problem is endorsed, affective/behavioral (A/B) andcognitive (Cog) scales; Satisfaction with Life Scale/SWLS, 35Zhighly satisfied to 5Zextremely dissatisfied; Rosenberg Self-esteem Scale/RSES, 10Zlow-self-esteem to 40Zhigh-self-esteem. Results: Apart from taking place outside a clinic, no consensus of what constituted “community-based treatment” emerged. In this specific CBP, all participants were determined by severity of brain injury, time-postonset, high life satisfaction, healthy self-esteem, and no complaints of impairment, except appraising their problem-solving ability as weak: SWLS (MdnZ25, IQRZ10.75), RSES (MdnZ31/IQRZ7.25), PCL-A/B (MdnZ.39/IQRZ.36), PCL-Cog (MdnZ.45/IQRZ.84); PSI-AA (MdnZ -1.87/IQRZ.88). Conclusions: Participants attended this CBP for up to 14yrs, making one characteristic of a CBP the potential lengthiness of its care. Taken together with the participants’ relatively negative self-appraisal of problem-solving ability, this characteristic could suggest a need for the reconceptualization of the meaning of “rehabilitation outcomes,” where the appropriateness of “discharge” [from treatment] is questioned.Future studies could examine
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