Traumatic brain injury occurring with spinal cord injury: significance for rehabilitation.

Research indicates that traumatic brain injury (TBI) often occurs with traumatic spinal cord injury (SCI). However, the literature strongly suggests that TBI frequently remains undiagnosed in the presence of an SCI; a situation that may account for some rehabilitation failure and unusual affective stance seen in SCI individuals. Rehabilitation programming with people who incur SCI is intensive, and includes relearning daily living skills (ADLs), and communication and vocational skills; efforts requiring the injured person to adequately attend to and process information. Cognitive and emotional sequelae of TBI can adversely effect learning and skills acquisition and, therefore, must be assessed early in the rehabilitation process. We review literature concerning concomitance of TBI and SCI, and, we present specific instruments to assess the presence of TBI in motorically restricted individuals. Finally, we present factors which complicate the assessment of TBI in the SCI population, and provide implications for rehabilitation assessment and intervention procedures.

Current trends in comprehensive spinal cord injury (SCI) management are toward early initiation of rehabilitation, often beginning immediately after injury (Woodbury & Redd, 1987). Rehabilitation of people with SCI is an intensive process that includes training in daily living skills, mobility, communication capabilities, and in psychosocial adaption to disability. In addition to the personnel intensity of therapy that is involved in the rehabilitation process, the financial cost of care is staggering. The National Spinal Cord Injury Data Statistical Center Annual Report (1990) cited the initial hospitalization and rehabilitation period (injury to home) for clients admitted to model systems from 1986 through 1990. The mean period for clients with incomplete paraplegia was 76.8 days; 84.4 days were average for persons with complete paraplegia, eighty-eight days were required for clients with incomplete quadriplegia, and 124.4 days were needed for people with complete quadriplegia. The mean total cost in 1990 dollars for the initial hospitalization and rehabilitation periods for clients reported on for 1987 through 1989 was $103,718 (Spinal Cord Injury, 1990).

A traumatic brain injury (TBI) concomitant with SCI can complicate and compromise rehabilitation efforts due in part to the deficits associated with brain injury. Cognitive impairments, including limitations in higher order executive functions, judgment, memory and functional language are common sequelae of TBI (Lezak 1987). Psychosocial effects associated with TBI may include egocentricity, denial, lability, disinhibition, agitation, depression, impulsivity and lethargy; symptoms which often mislabel people as lazy and uncooperative (Fraser, McMahon, & Voganthaler, 1988). Psychoemotional problems from TBI, in connection with the massive difficulties posed by SCI will make rehabilitation efforts even more challenging than usual. Successful rehabilitation is certainly possible when TBI and SCI occur together; if potential problems are properly assessed, identified, and integrated into treatment planning, chances are enhanced for achieving optimal rehabilitation outcomes.

Incidence

Demographics

Striking similarities are evident between the TBI and SCI populations in demographic profile as well as injury circumstances. The incidence of TBI is higher for males than for females (by more than 2:1) with over 50% of the population being between the ages of 15 and 24 (Jennett & Teasdale, 1981). Similarly, over 80% of all reported SCI cases occur to men (Buchanan, 1987) and over half the population is between 15 and 30, with the most common age being 18 years. Both populations most frequently incur injury from motor vehicle accidents (50% in both cases), falls (21% in both cases), and from mishaps occurring during sports activities (Buchanan & Nawoczenski, 1987; NIHF, 1985). The similar demographic and incidence profiles of people with TBI and SCI may indicate a correspondence between the two disabilities, and posits a higher than expected co-occurrence rate of these injuries. In a literature review, Morris, Roth and Davidoff (1986) reported an average 50% concomitance rate of TBI with SCI.

Empirical Research

Several studies have been conducted to determine the frequency of TBI co-occurring with SCI. Researchers have indeed found evidence of the commonplace nature of this phenomenon. Richards, Brown, Hagglund, Bua and Reeder (1988) administered a comprehensive neuropsychologic test battery to 150 persons with SCI shortly after they were injured. Richards et al. (1988) hypothesized that if TBI co-occurs with SCI, retesting at regular intervals would reveal improvement over time as some TBI effects abate. They found significant improvements in neuropsychological function across time in a pattern consistent with recovery from nonsevere brain injuries. According to this study, clinicians should be aware, especially early in the rehabilitation process, that their clients with SCI may also have TBI, and, therefore should be serially tested.

Davidoff, Morris, Roth and Bleiberg (1985) found that traumatic SCI is related to increased risk for cognitive dysfunction. They administered the Halstead Category Test (HCT) of the Halstead-Reitan Neuropsychological Battery (HRNB) (Golden, 1979; Hevern, 1980; Reitan & Davison, 1974) to 30 inpatients within eight weeks of injury. The researchers found that 57% of the subjects had HCT scores suggestive of abnormal cognitive functioning.

Wilmot, Cope, Hall and Acker (1985) found results of decreased cognitive functioning similar to Davidoff et al. (1985). They administered a series of motor free tests aimed at assessing cognitive impairment. Forty-three of the 67 patients (64%) scored in the impaired range on the test battery. Evidence of poor premorbid academic history was present in 19 (44%) of those with impaired performance on the neurological evaluation, 56% of the subjects had no previous record of scholastic difficulties. These studies were limited by their lack of controls, that is, criteria for impairment relied on levels of abnormality defined by test results in the general population and this should be taken into account when interpreting the results. Premorbid factors such as age, years of education, socioeconomic group or drug dependency may have influenced the performance of patients on the neuropsychological test battery (Davidoff et al. 1985).

Roth, Davidoff, Thomas, Dijkers, Berent, Klisz, and Yarkony (1987), in a preliminary study, administered a motor free neurologic test battery to 80 spinal cord injured patients, and 60 non-injured control subjects. Impairment levels were defined as scores which were more than two standard errors below mean values of the control subjects. Based on these definitions, abnormalities were found on all tests for between one-half and two-thirds of the subjects. By using control subjects, the researchers were able to demonstrate that neuropsychological deficits are common among spinal cord injured patients.

Roth, Davidoff, Thomas, Doljanac, Dijkers, Berent, Morris, and Yarkony (1989) conducted a further study utilizing control groups and assessing neuropsychological deficits in persons with SCI. Demographic factors were closely matched between patients and controls. Deficits were demonstrated by the subject group compared to controls on each test ranging from 10% to 40% below average levels. The Roth group compared test results of patients with SCI with those of controls and found persons with SCI demonstrated poor attention span and limited initial learning ability. They discovered other common neuropsychological deficits, including poor concentration ability, impaired memory function, and altered problem solving ability.

Silver, Morris and Otfinowski (1980) reviewed associated injuries in patients with SCI. Based on 100 consecutive admissions, they found that 75% of the patients had associated injuries, the most common being TBI, with chest injuries being the next most frequent. This study found 50 head injuries, 41 including a short period of unconsciousness. Nine of the head injuries were more serious, as shown by the length of pre- and post-traumatic amnesia, with subsequent confusion. Five had fractures of the skull and three had body fluids escaping from the ears or nose.

Providing further evidence of cognitive impairment among persons with recent SCI, Stutts, Kreutzer, Barth, Ryan, Hickman, Devany and Marwitz (1991) collected neuropsychological and demographic data in addition to administering a comprehensive battery of 11 neuropsychological tests on 89 persons with recent SCI. Between one-fourth and one-half of the subjects demonstrated impairment in most areas of cognitive functioning.

The literature makes a convincing case that brain injury is often concomitant with traumatic SCI. However, neurological evaluation and radiographic work-up of suspected head injury is not performed consistently with this population (Davidoff, Morris, Roth & Bleiberg, 1984). A retrospective study of closed head injury in SCI revealed that loss of consciousness (LOC) was assessed in only 67% of all rehabilitation hospital admissions and 87% of all emergency room admissions (Davidoff et al., 1984). Fewer than 25% of all patients in both settings were assessed for post-traumatic amnesia (PTA); LOC of 20 minutes' duration or a PTA lasting 24 hours have been associated with deficits in concentration, attention, memory, and higher-level cognitive functions (Jennett, 1972).

Neuropsychological

Assessment Procedures

Given the motor impairment characteristically seen in SCI, special considerations are necessary to assess neuropsychological status in this population. One method relies on modified batteries that eliminate the tests' motor requirements. The previously discussed studies utilized several combinations of instruments with modifications for motor impairment. Motor free scales most frequently used included the Halstead Category Test (Davidoff et al., 1985; Richards et al., 1988; Roth et al., 1989), Weschler Memory Scale and Associate Learning Tests (Wilmot et al, 1985; Richards et al, 1988; Roth et al., 1989), the Rey Auditory Verbal Learning Test (Richards et al., 1988; Roth et al., 1989) and the Stroop Color/Word Test (Wilmot et al., 1985; Richards et al., 1988). Other tests meeting motor free criteria include the Galveston Orientation and Amnesia Test (GOAT), Quick Test, Raven Progressive matrices, serial 7s, and the Shipley Hartford (Wilmot et al., 1985). Richards et al. (1988) also included the Benton Visual Retention Test, Benton Facial Recognition Test, Benton Judgment of Line Orientation Test, Russell Memory Test, Controlled Oral Word Association Test and Selective Reminding Task.

Research is limited as to the utility of these measurement tools in determining closed head injury in patients with SCI. However, Davidoff, Doljanac, Berent, Johnson, Thomas, Dijkers and Klisz (1988) conducted a study aimed at exploring the appropriateness of the Galveston Orientation and Amnesia Test (GOAT; Levin, O'Donnell & Grossman, 1979; Levin, Benton & Grossman, 1982) in establishing the diagnosis of head injury among persons with SCI. The GOAT consists of questions relating to orientation and memory such as "where were you born?; describe the last event you recall before the accident", etc. Davidoff et al. (1988) serially administered the GOAT to a group of inpatients over a period of several days. Based on a review of medical records alone, 23% of the patients were shown to have sustained a LOC and 20% experienced a period of PTA. The researchers found that the GOAT increased the demonstrable rate of PTA for 20% to 44% of the subjects. Davidoff et al. (1988) concluded that utilization of the GOAT inventory increased the sensitivity of the assessment of PTA, which becomes an indicator for further assessment of head injury.

Related Complications

There are several factors related to neuropsychological assessment of TBI and SCI that may encumber reliable testing, evaluation and diagnosis. Anoxia, substance abuse, premorbid functioning and affective disorder (primarily depression) are examples of mitigating factors for which the clinician must assess to insure valid data collection.

Anoxia. According to a study by Silver, Morris and Otfinowski (1980), a patient with a cervical or thoracic injury and signs of injury of the head may be confused secondary to anoxia from impaired ventilation and not by primary brain damage. Anoxic effects can mimic those seen in the acute phase of TBI recovery, so careful screening is necessary to avoid a false positive diagnosis of TBI. However, anoxia itself can be a primary cause of TBI (Kaplan, 1991), so serial neuropsychological examination, along with neurological follow-up is critical for correct diagnosis.

Substance abuse. Substance abuse often confounds the assessment of brain injury associated with SCI. We know that substance abuse and SCI coexist; this fact being well documented in the literature. Heinemann, Keen, Donohue and Schnoll (1988) studied the consequences of alcohol use in 103 persons with recent SCI and found that 95% of the sample acknowledged prior alcohol use. In addition, the mean weekday quantity of alcohol consumed was 5.9 drinks, with a range of one to 24 drinks per drinking episode during the six months before disability onset. (Heinemann et al. also administered the Michigan Alcoholism Screening Test (MAST) (Selzer, 1971), and found elevated scores for persons with SCI as compared to the general population.

Another study (Heinemann, Doll, Armstrong, Schnoll & Yarkony, 1991), collected data from 86 persons with SCI and found that the time of greatest substance use reported by participants occurred within six months prior to injury. Fullerton, Harvey, Klein and Howell (1981) found that 15 of 30 patients consecutively admitted to a hospital for SCI acknowledged drinking immediately prior to injury. Frisbie and Tun (1984) surveyed 137 patients with SCI and found that 101 (74%) had consumed an average of six drinks a day for 23 years. Ninety-two of these patients were habitual drinkers prior to SCI and 39 (28%) were drinking on the day of the injury. Further, O'Donnell, Cooper, Gessner, Shehan and Ashley (1981) found that 62% of their subjects were identified as having alcohol or drug related injuries.

Substance abuse has also been shown to contribute significantly to the occurrence of TBI (Sparadeo, Strauss & Barth, 1990; Sparadeo & Gill, 1989). A study by Kreutzer,Doherty, Harris and Zasler (1990) found a positive history of alcohol abuse or dependence prior to injury in 58% of TBI survivors. Further, it has been suggested that the presence of an elevated blood alcohol level at the time of injury may result in a more uneven course of recovery, with lower levels of consciousness, longer duration of coma and increased behavioral disturbance (Solomon & Sparadeo, 1992).

Alcohol or other drugs in the injured person's system can invalidate, or falsely retard performance on neuropsychological measures, another situation in which we might reach a false positive conclusion of TBI. A related issue concerns the debilitating effect of long term substance abuse on neuropsychological test performance and overall cognitive functioning. Overall deterioration of cognitive function might be attributed to the mechanical injury, rather than to long term substance abuse.

Premorbid functioning. Before making conclusions about current functioning, it is important to assess the level of cognitive functioning prior to injury. We need that information to get reasonable indications of change due to head injury. Reviewing academic records, previous job performance or premorbid testing can provide some background data. Haas, Cope and Hall (1987) studied 80 head injured patients and found poor premorbid academic performance in 50% of the sample. In this study, poor academic performance was defined by diagnosis of a learning disability, multiple failed academic subjects, or school dropout during secondary education. Information was obtained from school records, reports of premorbid examinations by pediatricians and school psychologists, and interviews with the parents. We may find no demonstrable cognitive debilitation secondary to possible TBI when present functioning is compared to predisability levels. However, failure to make these comparisons can result in either a false positive or false negative diagnosis of TBI, depending if the injured individual was unusually high or low functioning prior to trauma.

Affect. Affective disorders, particularly depression, can adversely influence cognitive functioning. While depression is not an inevitable consequence of SCI, it can still be present, and may affect assessment results.

Goulet Fisher, Sweet and Pfaelzer-Smith (1986) looked at the relationship between depression and neuropsychological performance. They diagnosed depression in 15 individuals using the Beck Depression Inventory and DSM-III criteria. They then administered neuropsychological tests to these individuals, and to 15 individuals in a control group. The researchers found that the depressed group consistently performed at a more impaired level than the control group, suggesting that affective disturbance negatively influences the subject's test performance.

Current literature is somewhat inconsistent regarding the coexistence of depression with SCI, but does suggest that the occurrence of depression meeting DSM-III-R criteria during the first six months post injury, ranges from 10% to 30% (Judd & Burrows, 1986; Fullerton, Harvey, Klein & Howell, 1981). Howell, Fullerton, Harvey and Klein (1981) evaluated 22 patients with recent SCI using a standardized interview and diagnostic process. They found 22% of subjects had diagnosable depressions less than six months after injury. Frank, Elliott, Corcoran and Wonderlich (1987) evaluated 32 patients using a semistructured interview that permitted diagnosis by DSM-III criteria for affective disorders. Of the 32 patients, 14 (44%) had a DSM-III diagnosis of depressive disorder, 12 (38%) had major depression (five with melancholia) and two (6%) were dysthymic. If the person with SCI is experiencing depression at the time of testing, the results may be rendered inaccurate due to slower reaction time and/or reduced concentration efficiency.

Summary

The literature clearly points out the high co-occurrence rate of TBI with SCI. It is also clear that dual diagnosis is frequently missed, and that the effects of a head injury can have strong negative impact on rehabilitation outcome. The client with SCI may fail to reach optimal function unless these problems are identified and addressed by rehabilitation professionals. By understanding the impact of cognitive impairments on client functions, rehabilitation professionals will be better able to provide appropriate programming and treatment plans. Also, an awareness of the emotional effects of FBI can allow us to more effectively work with the family as well as the person with SCI to facilitate positive rehabilitation outcome. Helping both the family and the individual identify and anticipate emotional shifts can encourage improved coping with the changes that occur due to injury. Finally, determining an accurate level of cognitive functioning is critical, because it may be associated with medical stability and with a person's ability to assimilate necessary post SCI survival and adaptation skills (Davidoff, Roth & Richards, 1992).

We must actively look for TBI in SCI cases, and we should have a high index of suspicion that they are concomitant. In doing so, our neuropsychological assessment measures will need modification to cope with the decreased upper extremity motor function of some people with SCI. In addition, other factors affecting assessment of this specific population, including anoxia, pre-morbid functioning, substance abuse and depression must be addressed. Eliminating the attitude of "one disability per customer" allows us to provide knowledgeable, effective rehabilitation services to individuals with head injuries concomitant with SCI.

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