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Systematic Review of Self-Reported Prognosis in Adults After Mild Traumatic Brain Injury
e60 Poster 174 Countywide Concussion Care Program Gillian Hotz (University of Miami Miller School of Medicine) Objective: To develop and implement a Countywide Concussion Care Program(TM) (CCCP) in order to standardize concussion management and reduce concussions in high school athletes that play contact sports. Design: Prospective study. Setting: In 2011, the Miami Dade County Public Schools Board mandated public high schools to follow a standardized concussion protocol. Participants: About 13,000 public high school athletes that participate in contact sports (football, soccer, lacrosse, basketball, wrestling) are included. Interventions: The CCCP protocol implemented includes: training and education of certified athletic trainers (ATC) and coaches, baseline sideline evaluation with SCAT 2, baseline ImPACT testing and retesting, clinic follow up to return to play, and a concussion injury surveillance form completed by all ATCs once the athlete returns to play. Main Outcome Measure(s): ImPACT testing results, clinic data, and surveillance form data. Results: Since 8/2011 there have been 13,397 high school athletes from the 36 public high schools with an average age of 15.5 years that have completed baseline ImPACT testing and 400 post tests (3%). Since 8/ 2012, the concussion clinic treated 165 athletes (football 124, soccer 17, basketball 13 etc). There have been 227 Concussion Injury Surveillance forms completed by the ATCs. Other data will be presented. Conclusions: A CCCP has been developed, implemented, and evaluated in Miami-Dade County. The protocol is continually being evaluated in order to reduce the number of concussions. Most recently concussion education using the Sports Legacy Institute Concussion Education (SLICE) program and King-Devick Test for sideline testing has been initiated. Key Words: High School, Concussion, Evaluation Disclosure(s): None disclosed. Poster 175 Integrative Cognitive Rehabilitation Program: An Innovative, Multidisciplinary Approach Heather E. Coles (University of Rochester Medical Center), Simon Carson, Nancy Dukelow, Jennifer Anne Fleeman, Sheryl Maier, Christopher Stavisky Objective: To develop a comprehensive, patient centered and multidisciplinary cognitive rehabilitation program, using the theoretical foundations of distributed cognition, neural plasticity, activity theory, and ICF (WHO, 2001). Incorporate technology as cognitive prosthetics. Develop and reinforce compensatory strategies to optimize cognitive functioning. Design: Single Subject Design. Optimize cognitive functioning in individuals with mild to moderate cognitive impairment using quantitative and qualitative outcome measures. Setting: Ambulatory. Participants: Participants are referred directly to the Integrative Cognitive Rehabilitation Program. Interventions: Treatment protocol which is patient centered with sessions of Occupational Therapy and Speech Language Pathology.Patients and clinicians together select from a menu of interventions to create an individualized treatment plan. Global interventions apply to all participants, including underwhelming approach, education, compensatory strategies, technology and homework. Main Outcome Measure(s): Quantitative Data includes pre test and post test measures on intake questionnaire and formal testing. Qualitative Data is gathered during assessment and measured prior to discharge from treatment. Results: Survey results indicate > 90% of individuals participating in the program found benefit from both occupational and speech therapy.
Brain Injury Participants communicated increased independence with return to school and work and overall greater participation in life. >10% reported they would have benefitted from more frequent sessions. Length of treatment ranged from 2 to 30 sessions. Conclusions: Patient Centered goals and caregiver involvement are critical to individual successes. Emotional and cognitive functioning are intertwined and targeted for positive outcomes. Need to standardize the complex treatment grid for greater efficiency with treatment execution. Need to compare outcomes of ICRP with traditional discipline specific approach. Key Words: Multidisciplinary, Cognitive, Clinical Practice Disclosure(s): None Disclosed. Poster 176 Risk of Cognitive Decline After Head Injury: A Population-Based Discordant Twin Control Study J. David Cassidy (University Health Network, University of Toronto), Eleanor Boyle, Jan Hartvigsen, Matt McGue, Victor Coronado, Kaare Christensen Objective: To determine if a history of head injury (HI) is a risk factor for cognitive decline in older Danish twins. Design: Discordant twin pair design nested in the cohort Longitudinal Study of Ageing Danish Twins (LSADT). Setting: The LSADT is a national population-based cohort study of older Danish twins in the Danish Twin Registry. Participants: Between 1995-2001, 4,731 twins, 70 years of age or older, underwent cognitive testing and were interviewed about past history of HI. HI was defined as hitting the head resulting in loss of consciousness or the presence of nausea or dizziness. Interventions: Not applicable. Main Outcome Measure(s): The Mini-Mental State Examination (MMSE) and five brief cognitive tests examining fluency, forward and backward digit span, and immediate and delayed memory recall were performed. Cognitive outcomes were compared between same-sex twin pairs discordant for exposure to HI using conditional logistic regression or multilevel linear regression. All models were adjusted for age, sex and educational level. Results: Of 4,221 twins interviewed, 322 same-sex twin pairs were discordant on HI exposure. Their mean age was 75.1 years, 58% were females, 36.3% monozygotic pairs, 62.4% dizygotic pairs and 1.2% unknown zygosity. Their educational level was 10.5% < 7 years, 84.3% 7-10 years and 5.2% >10 years. The MMSE was < 25 in 23.5% with HI and 21.6% without HI (ORZ1.26; 95% CI 0.79-2.01). There were no significant differences in any of the cognitive outcomes. Conclusions: We found no evidence that a history of HI affected cognitive function in older Danish twins. Key Words: twin study, brain concussion, mild cognitive impairment, risk factors, epidemiology Disclosure(s): None Disclosed. Poster 177 Systematic Review of Self-Reported Prognosis in Adults After Mild Traumatic Brain Injury James Donovan (University Health Network, University of Toronto), J. David Cassidy, Carol Cancelliere, Linda J. Carroll, Pierre Coˆte´, Cesar Hincapie, LenaLena W. Holm, Jan Hartvigsen, Catharina Nygren-de Boussard, Vicki Leigh Kristman, Jo¨rgen Borg Objective: To update the MTBI prognosis review published by the WHO Task Force in 2004. Design: Systematic review and best-evidence synthesis. Setting: MEDLINE, PsycINFO, Embase, CINAHL and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed
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Brain Injury studies. Controlled trials, cohort and case-control studies were selected according to predefined criteria. Participants: Studies were included with more than 30 adult MTBI cases. Interventions: Not applicable. Main Outcome Measure(s): Self-reported outcomes in adults. Results: Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including two of the three original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer pre-morbid mental and physical health status and with more injury-related stress. Most recover over one year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. Conclusions: Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues. Key Words: Persistent symptoms, Prognosis, Craniocerebral trauma, Recovery of function Disclosure(s): None Disclosed. Poster 178 Outcome Prediction in Home- and Community-Based Brain Injury Rehabilitation using the Mayo-Portland Adaptability Inventory James F. Malec (Indiana University School of Medicine/Rehabilitation Hospital of Indiana), Devan Parrott, Irwin Altman, Shannon Swick Objective: To develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation. Design: Retrospective data analysis. Setting: Data collected from 7 geographically distinct programs in a home- and community-based brain injury rehabilitation provider network Participants: 642 individuals post-traumatic brain injury. Interventions: Home- and community-based brain injury rehabilitation. Main Outcome Measure(s): Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Results: Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predictedExcellent (no to minimal participation limitations), Very Good (very mild participation limitations), Good (mild participation limitations), and Limited (significant participation limitations) outcome levels at discharge with acceptable accuracy (Wilks’ l Z .51, df Z 6, p Conclusions: Results demonstrate both the feasibility and validity of individual outcome predictions for HCBR based on quantitative data.Data obtained at admission can be used to describe the probability of specific levels of success that a given patient can expect to obtain as a result of active participation in HCBR.Predicting such outcome categories can be done with greater reliability than predicting specific outcome scores or arbitrary categories using linear or logistic regression, and arguably are more understandable to patients and families who are not versed in statistics and measurement. Key Words: Outcomes, Brain Injury, Prediction Disclosure(s): None Disclosed.
Poster 179 A Telehealth Approach to Improving Outcomes for Caregivers of Adults With Traumatic Brain Injury Janet M. Powell (University of Washington), Robert Fraser, Jo Ann, Ann Brockway, Nancy R. Temkin, Kathleen Reilly Bell Objective: To determine if a telephone-based, individualized mentored problem-solving and education intervention improves quality of life and
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e61 emotional well-being of caregivers of persons with traumatic brain injury (TBI). Design: Randomized controlled trial with blinded follow-up assessment at 6 months. Setting: General community. Participants: Caregivers of persons with moderate to severe TBI who received acute and/or rehabilitation care at a Level I trauma center.Caregivers were randomly assigned to intervention or usual care. Interventions: Individualized mentored problem-solving and education focused on caregivers’ primary concerns delivered via 7-10 telephone calls at 2-week intervals after discharge of the TBI survivor to the community. Main Outcome Measure(s): Caregiver quality of life and emotional wellbeing were assessed with a composite of the Bakas Caregiving Outcomes Scale (BCOS) and the Brief Symptom Inventory (BSI-18).Secondary measures included the Brief COPE. Results: 153 caregivers (mean age 49.7; 82% female; 54% spouses/partners, 35% parents) were enrolled with 125 (82%) assessed at 6 months. Caregivers in the treatment arm endorsed better quality of life and emotional well-being on the BCOS-BSI-18 composite score (pZ.032) with more active coping (pZ.020) and less emotional venting (pZ.028) on the Brief COPE.They also reported receiving more assistance from others, more success in gaining information from health care providers, and feeling better able to care for themselves. Conclusions: An individualized mentored problem-solving and education approach delivered via telephone in the first few months after TBI survivor community discharge resulted in better quality of life/emotional wellbeing for caregivers. Consideration should be given to using this approach to augment the support typically offered caregivers. Key Words: Telemedicine, Brain Injuries, Caregivers, Problem Solving, Randomized controlled trial Disclosure(s): None Disclosed. Poster 180 Impact of Headache Persistence on Psychological and Physical Functioning 1 Year After Traumatic Brain Injury Jeanne M. Hoffman (University of Washington), Sylvia Lucas, Sureyya Dikmen, Kathleen Reilly Bell Objective: To evaluate the impact of headache persistence for those with moderate to severe traumatic brain injury (TBI) over the first year on psychological and physical outcomes assessed at one year post injury. Design: Prospective cohort study. Setting: Community. Participants: 420 subjects enrolled during inpatient rehabilitation and followed at 3, 6, and 12 months post injury. Interventions: None. Main Outcome Measure(s): Mood was assessed using the Patient Health Questionnaire-9 (PHQ-9), quality of life with the Satisfaction with Life Scale (SWLS), participation using the Participation Assessment with Recombined Tools (PART), and motor and cognitive function outcome with FIMä. Headache persistence was assessed as (yes/no) across followup points adjusted for missing assessments (range from 0%Zno headache at any time, to 100%Zheadache at all times). Results: After adjusting for demographics and injury severity, headache persistence was found to be significantly related to higher reports of depressive symptoms, lower satisfaction with life, and lower cognitive FIM scores.Headache was unrelated to participation as measured by the 3 subscales (Productivity, Social, Out and About) and total score of the PART nor related to motor FIM scores. Conclusions: Headache persistence across the first year appears to be related to important psychological outcomes at 1 year suggesting that close monitoring and treatment of headache may be necessary to improve mood and satisfaction with life. Headaches over one year after TBI appear to be associated with cognitive complaints as well as problems with emotional health at one year after TBI. More research is needed to untangle the directionality of these relationships. Key Words: headache, traumatic brain injury, mood, cognition
Brain Injury Participants communicated increased independence with return to school and work and overall greater participation in life. >10% reported they would have benefitted from more frequent sessions. Length of treatment ranged from 2 to 30 sessions. Conclusions: Patient Centered goals and caregiver involvement are critical to individual successes. Emotional and cognitive functioning are intertwined and targeted for positive outcomes. Need to standardize the complex treatment grid for greater efficiency with treatment execution. Need to compare outcomes of ICRP with traditional discipline specific approach. Key Words: Multidisciplinary, Cognitive, Clinical Practice Disclosure(s): None Disclosed. Poster 176 Risk of Cognitive Decline After Head Injury: A Population-Based Discordant Twin Control Study J. David Cassidy (University Health Network, University of Toronto), Eleanor Boyle, Jan Hartvigsen, Matt McGue, Victor Coronado, Kaare Christensen Objective: To determine if a history of head injury (HI) is a risk factor for cognitive decline in older Danish twins. Design: Discordant twin pair design nested in the cohort Longitudinal Study of Ageing Danish Twins (LSADT). Setting: The LSADT is a national population-based cohort study of older Danish twins in the Danish Twin Registry. Participants: Between 1995-2001, 4,731 twins, 70 years of age or older, underwent cognitive testing and were interviewed about past history of HI. HI was defined as hitting the head resulting in loss of consciousness or the presence of nausea or dizziness. Interventions: Not applicable. Main Outcome Measure(s): The Mini-Mental State Examination (MMSE) and five brief cognitive tests examining fluency, forward and backward digit span, and immediate and delayed memory recall were performed. Cognitive outcomes were compared between same-sex twin pairs discordant for exposure to HI using conditional logistic regression or multilevel linear regression. All models were adjusted for age, sex and educational level. Results: Of 4,221 twins interviewed, 322 same-sex twin pairs were discordant on HI exposure. Their mean age was 75.1 years, 58% were females, 36.3% monozygotic pairs, 62.4% dizygotic pairs and 1.2% unknown zygosity. Their educational level was 10.5% < 7 years, 84.3% 7-10 years and 5.2% >10 years. The MMSE was < 25 in 23.5% with HI and 21.6% without HI (ORZ1.26; 95% CI 0.79-2.01). There were no significant differences in any of the cognitive outcomes. Conclusions: We found no evidence that a history of HI affected cognitive function in older Danish twins. Key Words: twin study, brain concussion, mild cognitive impairment, risk factors, epidemiology Disclosure(s): None Disclosed. Poster 177 Systematic Review of Self-Reported Prognosis in Adults After Mild Traumatic Brain Injury James Donovan (University Health Network, University of Toronto), J. David Cassidy, Carol Cancelliere, Linda J. Carroll, Pierre Coˆte´, Cesar Hincapie, LenaLena W. Holm, Jan Hartvigsen, Catharina Nygren-de Boussard, Vicki Leigh Kristman, Jo¨rgen Borg Objective: To update the MTBI prognosis review published by the WHO Task Force in 2004. Design: Systematic review and best-evidence synthesis. Setting: MEDLINE, PsycINFO, Embase, CINAHL and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed
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Brain Injury studies. Controlled trials, cohort and case-control studies were selected according to predefined criteria. Participants: Studies were included with more than 30 adult MTBI cases. Interventions: Not applicable. Main Outcome Measure(s): Self-reported outcomes in adults. Results: Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including two of the three original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer pre-morbid mental and physical health status and with more injury-related stress. Most recover over one year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. Conclusions: Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues. Key Words: Persistent symptoms, Prognosis, Craniocerebral trauma, Recovery of function Disclosure(s): None Disclosed. Poster 178 Outcome Prediction in Home- and Community-Based Brain Injury Rehabilitation using the Mayo-Portland Adaptability Inventory James F. Malec (Indiana University School of Medicine/Rehabilitation Hospital of Indiana), Devan Parrott, Irwin Altman, Shannon Swick Objective: To develop statistical formulas to predict levels of community participation on discharge from post-hospital brain injury rehabilitation. Design: Retrospective data analysis. Setting: Data collected from 7 geographically distinct programs in a home- and community-based brain injury rehabilitation provider network Participants: 642 individuals post-traumatic brain injury. Interventions: Home- and community-based brain injury rehabilitation. Main Outcome Measure(s): Mayo-Portland Adaptability Inventory (MPAI-4) Participation Index. Results: Linear discriminant models using admission MPAI-4 Participation Index score and log chronicity correctly predictedExcellent (no to minimal participation limitations), Very Good (very mild participation limitations), Good (mild participation limitations), and Limited (significant participation limitations) outcome levels at discharge with acceptable accuracy (Wilks’ l Z .51, df Z 6, p Conclusions: Results demonstrate both the feasibility and validity of individual outcome predictions for HCBR based on quantitative data.Data obtained at admission can be used to describe the probability of specific levels of success that a given patient can expect to obtain as a result of active participation in HCBR.Predicting such outcome categories can be done with greater reliability than predicting specific outcome scores or arbitrary categories using linear or logistic regression, and arguably are more understandable to patients and families who are not versed in statistics and measurement. Key Words: Outcomes, Brain Injury, Prediction Disclosure(s): None Disclosed.
Poster 179 A Telehealth Approach to Improving Outcomes for Caregivers of Adults With Traumatic Brain Injury Janet M. Powell (University of Washington), Robert Fraser, Jo Ann, Ann Brockway, Nancy R. Temkin, Kathleen Reilly Bell Objective: To determine if a telephone-based, individualized mentored problem-solving and education intervention improves quality of life and
www.archives-pmr.org
e61 emotional well-being of caregivers of persons with traumatic brain injury (TBI). Design: Randomized controlled trial with blinded follow-up assessment at 6 months. Setting: General community. Participants: Caregivers of persons with moderate to severe TBI who received acute and/or rehabilitation care at a Level I trauma center.Caregivers were randomly assigned to intervention or usual care. Interventions: Individualized mentored problem-solving and education focused on caregivers’ primary concerns delivered via 7-10 telephone calls at 2-week intervals after discharge of the TBI survivor to the community. Main Outcome Measure(s): Caregiver quality of life and emotional wellbeing were assessed with a composite of the Bakas Caregiving Outcomes Scale (BCOS) and the Brief Symptom Inventory (BSI-18).Secondary measures included the Brief COPE. Results: 153 caregivers (mean age 49.7; 82% female; 54% spouses/partners, 35% parents) were enrolled with 125 (82%) assessed at 6 months. Caregivers in the treatment arm endorsed better quality of life and emotional well-being on the BCOS-BSI-18 composite score (pZ.032) with more active coping (pZ.020) and less emotional venting (pZ.028) on the Brief COPE.They also reported receiving more assistance from others, more success in gaining information from health care providers, and feeling better able to care for themselves. Conclusions: An individualized mentored problem-solving and education approach delivered via telephone in the first few months after TBI survivor community discharge resulted in better quality of life/emotional wellbeing for caregivers. Consideration should be given to using this approach to augment the support typically offered caregivers. Key Words: Telemedicine, Brain Injuries, Caregivers, Problem Solving, Randomized controlled trial Disclosure(s): None Disclosed. Poster 180 Impact of Headache Persistence on Psychological and Physical Functioning 1 Year After Traumatic Brain Injury Jeanne M. Hoffman (University of Washington), Sylvia Lucas, Sureyya Dikmen, Kathleen Reilly Bell Objective: To evaluate the impact of headache persistence for those with moderate to severe traumatic brain injury (TBI) over the first year on psychological and physical outcomes assessed at one year post injury. Design: Prospective cohort study. Setting: Community. Participants: 420 subjects enrolled during inpatient rehabilitation and followed at 3, 6, and 12 months post injury. Interventions: None. Main Outcome Measure(s): Mood was assessed using the Patient Health Questionnaire-9 (PHQ-9), quality of life with the Satisfaction with Life Scale (SWLS), participation using the Participation Assessment with Recombined Tools (PART), and motor and cognitive function outcome with FIMä. Headache persistence was assessed as (yes/no) across followup points adjusted for missing assessments (range from 0%Zno headache at any time, to 100%Zheadache at all times). Results: After adjusting for demographics and injury severity, headache persistence was found to be significantly related to higher reports of depressive symptoms, lower satisfaction with life, and lower cognitive FIM scores.Headache was unrelated to participation as measured by the 3 subscales (Productivity, Social, Out and About) and total score of the PART nor related to motor FIM scores. Conclusions: Headache persistence across the first year appears to be related to important psychological outcomes at 1 year suggesting that close monitoring and treatment of headache may be necessary to improve mood and satisfaction with life. Headaches over one year after TBI appear to be associated with cognitive complaints as well as problems with emotional health at one year after TBI. More research is needed to untangle the directionality of these relationships. Key Words: headache, traumatic brain injury, mood, cognition