Clinical progression and outcome of dysphagia following paediatric traumatic brain injury: a prospective study

Objectives : To provide a preliminary clinical profile of the resolution and outcomes of oral-motor impairment and swallowing function in a group of paediatric dysphagia patients post-traumatic brain injury (TBI). To document the level of cognitive impairment parallel to the return to oral intake, and to investigate the correlation between the resolution of impaired swallow function versus the resolution of oral-motor impairment and cognitive impairment. Participants : Thirteen children admitted to an acute care setting for TBI. Main outcome measures : A series of oral-motor (Verbal Motor Production Assessment for Children, Frenchay Dysarthria Assessment, Schedule for Oral Motor Assessment) and swallowing (Paramatta Hospital's Assessment for Dysphagia) assessments, an outcome measure for swallowing (Royal Brisbane Hospital's Outcome Measure for Swallowing), and a cognitive rating scale (Rancho Level of Cognitive Functioning Scale). Results : Across the patient group, oral-motor deficits resolved to normal status between 3 and 11 weeks post-referral (and at an average of 12 weeks post-injury) and swallowing function and resolution to normal diet status were achieved by 3-11 weeks post-referral (and at an average of 12 weeks post-injury). The resolution of dysphagia and the resolution of oral-motor impairment and cognitive impairment were all highly correlated. Conclusion : The provision of a preliminary profile of oral-motor functioning and dysphagia resolution, and data on the linear relationship between swallowing impairment and cognition, will provide baseline information on the course of rehabilitation of dysphagia in the paediatric population post-TBI. Such data will contribute to more informed service provision and rehabilitation planning for paediatric patients post-TBI.

Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

Primary objective: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. Research design: Programme evaluation using pre-and post-intervention assessments and telephone follow-up. Methods and procedures: Three participants with traumatic brain injury completed 8 weeks of training with 1 - 2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. Experimental interventions: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. Main outcomes and results: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. Conclusion: A compensatory approach may be useful in improving prospective memory performance following TBI.

Language outcomes subsequent to treatment of brainstem tumour in childhood

While the occurrence and management of brainstem tumours in children would not traditionally indicate potential direct structural impact on classical language centres, recent theories have implicated some involvement of the brainstem in a functional language and cognitive neural loop between the cerebellum and the cerebral hemispheres. Thus, the present paper explored the impact of treatment for brainstem tumour on the general and high-level language abilities of six children treated for brainstem tumour, in addition to phonological awareness skills. Group analysis revealed that children treated for brainstem tumour demonstrated intact language and phonological awareness abilities in comparison to an age- and gender-matched control group. Individual analysis revealed only one of six children treated for brainstem tumour revealed evidence of language disturbances, with an additional child demonstrating an isolated mildly reduced score on one phonological awareness task. Language deficits identified in a child treated with a combination of both radiotherapy and chemotherapy were noted in the high-level language area of lexical generation. Findings highlighted that no overt language disturbances were evident in children treated for brainstem tumour. However, further analysis into higher-level language skills in the present study indicated that both general and high-level language abilities require long-term monitoring in this population.

Kinematic analysis of jaw function in children following traumatic brain injury

Primary objective: To investigate jaw movements in children following traumatic brain injury (TBI) during speech using electromagnetic articulography (EMA). Methods and procedures: Jaw movements of two non-dysarthric children ( aged 12.75 and 13.08 years) who had sustained a TBI were recorded using the AG-100 EMA system (Carstens Medizineletronik) during word-initial consonant productions. Mean quantitative kinematic parameters and coefficient of variation ( variability) values were calculated and individually compared to the mean values obtained by a group of six control children ( mean age 12.57 years, SD 1.52). Main outcomes and results: The two children with TBI exhibited word-initial consonant jaw movement durations that were comparable to the control children, with sub-clinical reductions in speed being offset by reduced distances. Differences were observed between the two children in jaw kinematic variability, with one child exhibiting increased variability, while the other child demonstrated reduced or comparable variability compared to the control group. Conclusions: Possible sub-clinical impairments of jaw movement for speech were exhibited by two children who had sustained a TBI, providing insight into the consequences of TBI on speech motor control development.

Differential motor speech outcomes in children treated for mid-line cerebellar tumour

Primary objective: To investigate the nature of the motor speech impairments and dysarthria that can arise subsequent to treatment for childhood mid-line cerebellar tumours (CMCT). Research design: The motor speech ability of six cases of children with CMCT was analysed using perceptual and physiological measures and compared with that of a group of non-neurologically impaired children matched for age and sex. Main outcome and results: Three of the children with CMCT were perceived to exhibit dysarthric speech, while the remaining three were judged to have normal speech. The speech disorder in three of the children with CMCT was marked by deviances in prosody, articulation and phonation. The underlying pathophysiology was linked to cerebellar damage and expressed as difficulty in co-ordinating the motor speech musculature as required for speech production. These deficits were not identified in the three non-dysarthric children with CMCT. Conclusion: Differential motor speech outcomes occur for children treated for CMCT and these are discussed within the realm of possible mechanisms responsible for these differences. The need for further investigation of the risk factors for development of motor speech impairment in children treated for CMCT is also highlighted.

Caregiver burden, time spent caring and health status in the first 12 months following stroke

Objective: To quantify time caring, burden and health status in carers of stroke patients after discharge from rehabilitation; to identify the potentially modifiable sociodemographic and clinical characteristics associated with these outcomes. Methods: Patients and carers prospectively interviewed 6 (n = 71) and 12 (n = 57) months after discharge. Relationships of carer and patient variables with burden, health status and time analysed by Gaussian and Poisson regression. Results: Carers showed considerable burden at 6 and 12 months. Carers spent 4.6 and 3.6 hours per day assisting patients with daily activities at 6 and 12 months, respectively. Improved patient motor and cognitive function were associated with reductions of up to 20 minutes per day in time spent in daily activities. Better patient mental health and cognitive function were associated with better carer mental health. Conclusions: Potentially modifiable factors such as these may be able to be targeted by caregiver training, support and education programmes and outpatient therapy for patients.

Articulatory function following traumatic brain injury in childhood: A perceptual and instrumental analysis

Primary objective: To investigate the articulatory function of a group of children with traumatic brain injury (TBI), using both perceptual and instrumental techniques. Research design: The performance of 24 children with TBI was assessed on a battery of perceptual (Frenchay Dysarthria Assessment, Assessment of Intelligibility of Dysarthric Speech and speech sample analysis) and instrumental ( lip and tongue pressure transduction systems) assessments and compared with that of 24 non-neurologically impaired children matched for age and sex. Main outcomes: Perceptual assessment identified consonant and vowel imprecision, increased length of phonemes and overall reduction in speech intelligibility, while instrumental assessment revealed significant impairment in lip and tongue function in the TBI group, with rate and pressure in repetitive lip and tongue tasks particularly impaired. Significant negative correlations were identified between the degree of deviance of perceptual articulatory features and decreased function on many non-speech measures of lip function, as well as maximum tongue pressure and fine force tongue control at 20% of maximum tongue pressure. Additionally, sub-clinical articulatory deficits were identified in the children with TBI who were non-dysarthric. Conclusion: The results of the instrumental assessment of lip and tongue function support the finding of substantial articulatory dysfunction in this group of children following TBI. Hence, remediation of articulatory function should be a therapeutic priority in these children.

The effects of a song-singing programme on the affective speaking intonation of people with traumatic brain injury

Primary objective: To examine changes in the relationship between intonation, voice range and mood following music therapy programmes in people with traumatic brain injury. Research design: Data from four case studies were pooled and effect size, ANOVA and correlation calculations were performed to evaluate the effectiveness of treatment. Methods and procedures: Subjects sang three self-selected songs for 15 sessions. Speaking fundamental frequency, fundamental frequency variability, slope, voice range and mood were analysed pre- and post-session. Results: Immediate treatment effects were not found. Long-term improvements in affective intonation were found in three subjects, especially in fundamental frequency. Voice range improved over time and was positively correlated with the three intonation components. Mood scale data showed that immediate effects were in the negative direction whereas there weres increases in positive mood state in the longer-term. Conclusions: Findings suggest that, in the long-term, song singing can improve vocal range and mood and enhance the affective intonation styles of people with TBI.

Objective and behavioural assessment of the emergence from post-traumatic amnesia (PTA)

Primary objective: To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA. Research design: Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis. Methods and procedures: Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics. Main outcomes and results: Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA. Conclusions: It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.

Treating dysarthria following traumatic brain injury: Investigating the benefits of commencing treatment during post-traumatic amnesia in two participants

Primary objective: The aims of this preliminary study were to explore the suitability for and benefits of commencing dysarthria treatment for people with traumatic brain injury (TBI) while in post-traumatic amnesia ( PTA). It was hypothesized that behaviours in PTA don't preclude participation and dysarthria characteristics would improve post-treatment. Research design: A series of comprehensive case analyses. Methods and procedures: Two participants with severe TBI received dysarthria treatment focused on motor speech deficits until emergence from PTA. A checklist of neurobehavioural sequelae of TBI was rated during therapy and perceptual and motor speech assessments were administered before and after therapy. Main outcomes and results: Results revealed that certain behaviours affected the quality of therapy but didn't preclude the provision of therapy. Treatment resulted in physiological improvements in some speech sub-systems for both participants, with varying functional speech outcomes. Conclusions: These findings suggest that dysarthria treatment can begin and provide short-term benefits to speech production during the late stages of PTA post-TBI.

The rapid screen of concussion: An evaluation of the non-word repetition test for use in mTBI research

Primary objectives: (1) To investigate the Nonword Repetition test (NWR) as an index of sub-vocal rehearsal deficits after mild traumatic brain injury (mTBI); (2) to assess the reliability, validity and sensitivity of the NWR; and (3) to compare the NWR to more sensitive tests of verbal memory. Research design: An independent groups design. Methods and procedures: Study 1 administered the NWR to 46 mTBI and 61 uninjured controls with the Rapid Screen of Concussion (RSC). Study 2 compared mTBI, orthopaedic and uninjured participants on the NWR and the Hopkins Verbal Learning Test (HVLT-R). Main outcomes and results: The NWR did not improve the diagnostic accuracy of the RSC. However, it is reliable and indexes sub-vocal rehearsal speed. These findings provide evidence that although the current form of the NWR lacks sensitivity to the impact of mTBI, the development of a more sensitive test of sub-vocal rehearsal deficits following mTBI is warranted.