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John OLVER AM MBBS MD FAFRM (RACP)

Director Rehabilitation Epworth HealthcareProfessor Rehabilitation MedicineDepartment of Medicine Monash University

Long-Term Functional Outcome after Acquired Brain Injury (ABI)

0 10 20 30 40 50 60 70 80

Fatigue

Balance

Hearing

Smell

Vision

Headaches

Dizziness

Epilepsy

%

1 year post-injury

2 year post-injury

3 year post-injury

5 year post-injury

10 year post-injury

Neurological Complaints by years post-injury

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Areas responsible for olfactory functioning are vulnerable post TBI (due to the mechanics of the injury)

Injuries such as facial fractures (23.3% of patients) can damage sinonasal structures and limbic system which are central to sense of smell and taste

Olfactory impairment can affect 50-60% of patients yet is not routinely assessed in clinical settings. This results in significant rates of unawareness of the deficit

Olfactory Functioning – Sense of Smell

Drummond et al., 2015 ; Zandi & Hoseini, 2013

TEXT Loss of Sense of Smell Limitations

3. Food Preparation/Enjoyment

Unable to detect flavour (excessive use of salt/condiments)

Restrict engagement in social occasions based around food

1. Personal Safety (most serious)

Inability to detect gas, smoke or spoiled food. Can result in excessive checking (e.g. stoves)

4. Employment

Can affect employment (gas workers, chefs)

5. Personal Hygiene

Inability to monitor self body odours after exercise. Inability to determine whether clothes need washing

2. Relationships

Familiar smells of loved ones are lost, reduced intimacy

Drummond et al., 2013

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Identify the incidence of olfactory impairment in a consecutive sample of 134 adults post TBI admitted to Epworth HealthCare for rehabilitation

Compare the sensitivity and specificity of an olfactory function assessment scale which uses microencapsulation technique (scratch ‘n’ sniff)

UPSIT (Uni of Pennsylvania Smell Identification Test)

Investigate whether age, duration of post traumatic amnesia and facial fractures significantly predict the severity of olfactory impairment

Olfactory Impairment post TBI 3 Study Aims

Drummond et al., 2015

Olfactory Impairment post TBI Incidence using UPSIT

Drummond et al., 2015

66.4% of participants demonstrated olfactory impairment (12% more than the PST)

Of these patients, 25% had no sense of smell

In addition, 56% of patients were unaware that they had olfactory impairment

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Patient with olfactory impairment were:-

- Significantly older than those unimpaired and had worse injury severity (PTA) (non-sig)

Mean UPSIT score did not differ significantly for those with or without facial fractures

Only age and injury severity (PTA) significantly predicted UPSIT performance (10.3% total variance explained)

Participants were then followed up at 6 and 12 months post injury

Olfactory Impairment post TBI Predicting Olfactory Impairment

Drummond et al., 2015

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Results

Although 68% (n=32) showed some improvement from baseline, only 1 in 4 scored within the normal range and these patients had mild olfactory impairment at baseline

Baseline assessment was the only significant predictor of 12month outcome (73.5% of the variance). Age, injury severity and facial factors were non-significant predictors

Study Aim

6-month follow up study investigated the natural progression and associated predictors of olfactory impairment from baseline

Participants / Method

Of the original sample who had OI (n=89), 47 adults participated. Mean age 43.1 years, mostly post severe TBI. Patients administered the UPSIT

Phase 3 – Olfactory Impairment at 6mths

Drummond et al., 2017

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Results

83.3% of patients presented with olfactory impairment(with 24% being completely anosmic)

44.4% did not show any improvement from baseline and 11.1% had a more severe level of olfactory impairment (only 1 in 6 reached normal limits)

Baseline assessment continued to be the only significant predictor of 12month outcome (61% of the variance)

Study Aim

To investigate the natural progression and predictive factors (age, injury severity, baseline UPSIT score) of olfactory impairment at 12 months post initial assessment

Participants / Method

37 adults (out of 76 eligible participants); mean age 42.3 years and predominately severe TBI. Patients re-administered the UPSIT and interview of experiences of having olfactory impairment

Phase 3 – Olfactory Impairment at 12mths

Drummond et al., 2017

Concussion

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‘A clinical syndrome characterized by immediate and

transient alteration in brain function from a mechanical force or trauma.’ It is a mild injury to the brain causing temporary disruption of normal brain function. Loss of consciousness (10-20% cases). Concussion should be seen as

an evolving injury in that symptoms might be delayed for several hours. 80-90% of

concussions will resolve within 7-10 days

What is Concussion?

American Association of Neurological Surgeons, (n.d.); Finch et al., 2013

Pathophysiology of Concussion – Acute?

Acute Pathophysiology:-

Ion imbalance, metabolic disruptions, blood flow abnormalities, autonomic nervous system dysfunction. K efflux, glutamate release, mitochondrial Ca overload and dec ATP production. Trying to restore ion balance turns on ATP pump and creates an energy crisis with the decreased ATP causing “spreading depression.” Resolves 1-4 weeks

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Psychological component

Post Concussion Syndrome:- 3 or more symptoms for 4 weeks)

Persisting ion imbalance Persisting autonomic dysfunction

Cervicogenic injury (causing neck pain and restriction, headache, numbness and tingling in arms or legs, dizziness, vomiting, tinnitus, visual problems

Pathophysiology of Concussion – PCS?

Acute Concussion

Subacute Concussion

Chronic Concussion

2 Weeks

4 Weeks

6 Weeks

8 Weeks

10 Weeks

12 Weeks

14 Weeks

Injury16

Weeks

80% Recover during this

stage

20% Take Longer: This is

who we see

The Three Groups

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Epworth Concussion Clinic Patient Demographics (n=165)

GenderMale 52.1%

Female 47.9%

Mean

Age35.38 years (14 – 77)

Medical

History

Anxiety 31.0%

Depression 24.2%

Traumatic Brain Injury

10.9%

Employment

Categories

Full-time 50.9%

Part-time 14.5%

Student (full-time)

12.1%Injury

Details

Loss Of

Consciousness 43.0%

First Concussion 45.5%

Number of prior

concussions1.84 (0 – 12)

Post-Concussion Symptom Checklist

Dischinger et al., 2009

4 symptoms can be diagnosed as post concussive syndrome

Physical symptoms are most common (cognitive/emotional symptoms are likely to persist longer than 3mth)

The best predictors of symptom persistence are noise sensitivity and anxiety

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PCS Checklist Preliminary Results (n = 60; time in clinic = 124 days

On admission to the clinic, physical and thinking symptoms were the most prominent (increased number/severity of symptoms)

By discharge, all symptom categories significantly decreased

There was also a significant increase in patients’ typical daily activity levels from admission (41.5%) to discharge (79.3%)

17.48

10.53

6.48 6.556.80

3.252.22 2.73

0

2

4

6

8

10

12

14

16

18

20

Physical Thinking Sleep Emotional

Admission to Clinic Discharge from Clinic

*significant difference p <.05

*

** *

Significant decrease in patient stress, anxiety and depression scores between admission to discharge (p <.05)

On admission, average anxiety levels were considered moderate and mild levels of depression

By discharge, patients achieved ‘normal levels’ on all three subscales

11.26

4.97

12.65

5.00

9.35

3.71

0

2

4

6

8

10

12

14

Admission Discharge

Depression Anxiety Stress

Depression Anxiety Stress Scale (preliminary, n=44)

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Brief Illness Perception Questionnaire (preliminary, n=43)

Key Item Scoring

Control How much control do you feel you have over your illness?

0 = absolutely no control; 10 = extreme amount of control

Symptoms How much do you experience symptoms from your illness?

0 = no symptoms at all; 10 = many severe symptoms

Concern How concerned are you about your illness 0 = not at all concerned; 10 = extremely concerned

Graph illustrates results from 3 questions on the BIPQ. There were significant, positive changes for all 8 questions

All other items on the BIPQ showed statistically significant changes from admission to discharge

Effect sizes were large for the three items displayed (e.g. Cohen’s d = 1.01 – 1.47)

Case Study Two – Female, 59 year old

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Referral to Epworth Concussion Clinic

At the time, she was only managing 1-2 hours of work per day over 7 days. Subsequently referred to Epworth Concussion Clinic 1 month later (23rd August 17)

Concussion Details

Patient works from home and took a break going outside holding a washing basket

She went outside and lost balance, falling backwards hitting the back of her head on the windowsill. LOC for a few seconds, does not recall the fall (22nd June)

Acute and Ongoing Symptoms

Increased dizziness and nausea. Markedly increased anxiety when approached from behind

hospital ER: CT – no abnormalities and she was sent home. Saw a local doctor weekly – symptoms not improving

Past medical history: anxiety disorder, osteoarthritis

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Case Study Two Discharge Symptom Checklist

Symptoms none mild moderate severe P

hys

ica

l

Headache 0 1 2 3 4 5 6

Nausea 0 1 2 3 4 5 6

Vomiting 0 1 2 3 4 5 6

Balance Problem 0 1 2 3 4 5 6

Dizziness 0 1 2 3 4 5 6

Visual Problems 0 1 2 3 4 5 6

Fatigue 0 1 2 3 4 5 6

Sensitivity to Light 0 1 2 3 4 5 6

Sensitivity to Noise 0 1 2 3 4 5 6

Numbness/Tingling 0 1 2 3 4 5 6

Pain other than Headache 0 1 2 3 4 5 6

Th

inki

ng

Feeling Mentally Foggy 0 1 2 3 4 5 6

Feeling Slowed Down 0 1 2 3 4 5 6

Difficulty Concentrating 0 1 2 3 4 5 6

Difficulty Remembering 0 1 2 3 4 5 6

Sle

ep

Drowsiness 0 1 2 3 4 5 6

Sleeping Less than Usual 0 1 2 3 4 5 6

Sleeping More than Usual 0 1 2 3 4 5 6

Trouble Falling Asleep 0 1 2 3 4 5 6

Em

oti

on

al Irritability 0 1 2 3 4 5 6

Sadness 0 1 2 3 4 5 6

Nervousness 0 1 2 3 4 5 6

Feeling More Emotional 0 1 2 3 4 5 6

Patient was treated within the clinic for 61 days. On discharge, all symptoms completely resolved

On discharge, the patient was able to manage 90% of her usual daily activities (+60% change) and the patient resumed bike riding, swimming and paddle boarding

As a result of the experience, she changed her job and initiated a home business – developing an online programme of mindfulness, yoga and stress reduction techniques

https://www.safetyandquality.gov.au

Patient Reported Outcomes Measures – PROMs (ABI)

‘PROMs are questionnaires which patients complete. They ask for the patient’s assessment of how health services and interventions have, over time, affected their quality of life, daily functioning, symptom severity, and other dimensions of health which only patients can know. PROMs promise to fill a vital gap in our knowledge about outcomes and about whether healthcare interventions actually make a difference to people’s lives.’

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Global Stroke Community Advisory Panel (GSCAP)

GSCAP consists of 21 multidisciplinary stroke experts from 9 countries (Australia – 2, Austria, Canada, France, Germany, Singapore, Sweden, UK and USA)

Created by Allergan to improve education surrounding spasticity, stroke and post-stroke care. As part of the latter, GSCAP produced a checklist identifying ongoing, common problems post stroke

Participants / Method

37 adults; mean age 42.3 years and predominately severe TBI. Patients administered the UPSIT and interview of experiences of having olfactory impairment

Post Stroke Checklist Development

A list of the most common problems patients experience post stroke was initially generated by the GSCAP

Using Delphi methods, a consensus was reached on which of these problem areas were most important and relevant to include in the PSC

Swedberg 2017 ; Ekeland et al., 2017 ; Hagel 2005 ; Philp et al., 2012

- Designed as simple “easy to do” checklist- Provides a standardised approach for the identification of

long-term problems in stroke survivors- Covers wider aspects of quality of life- Should be carried out with patient (and care giver if needed)

- Ask patient each question, indicating the answer in the “response section”

- Generally, if answer is “No” observe patient’s progress- If answer is “Yes, follow-up with appropriate action

Following the trials of this checklist in Australia and other countries…. Could it be used as a PROM for TBI?

What?

How?

Most Common Issues Post Stroke Reported to General Practitioners Post Stroke Checklist (PSC) Version II

Philp et al., 2012

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Philp et al., 2012

The PSC was developed to help healthcare professionals identify the occurrence of 10 common persisting sequelae post-stroke that are amenable to treatment and suggests appropriate referral for treatment

Common long-term issues post stroke

Referral for treatment according to the patient’s response

Follow up questions to determine the impact of long-term problems

Philp et al., 2012

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Study Aim and Methodology

This international, collaborative study trialled the Post Stroke Checklist (PSC) in an Australian and Chinese population. The primary aim is to identify the frequency of long-term problems in patients at six months post stroke

PARTICIPANTS

210 participants were recruited from consecutive admissions to three stroke units (across Australia - 113 and China – 97)

Patients were administered the PSC at 6 months post injury and were also asked three questions relating to their satisfaction with the PSC and its relevance to their needs

Of the sample, 82.4% of patients have reported at least one deficit at 6 months. On average, patients were experiencing 3 problems at 6 months post stroke (SD=2.556, range = 0 – 10)

Post Stroke Checklist Study Results

The most prevalent symptom groups were:life difficulties, cognition,activities of daily living,mobility, mood and spasticity (all found to be the

most common issues as per Iosa et al. paper except for ADL)

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Patients have reported high levels of satisfaction with

the PSC (9.16 / 10)

Patients also considered the

checklist highly relevant and felt it identified their needs correctly

(9.22 / 10)

A third of patients requested their PSC responses be relayed

to a healthcare professional

Post Stroke Checklist – Patient Satisfaction

21.9%

26.6%

34.4%

50.0%

26.6%

28.1%

37.5%

42.2%

53.1%

43.7%

40.6%

29.3%

70.7%

75.6%

73.2%

43.9%

41.5%

39.0%

65.9%

56.1%

51.2%

63.4%

10.0%

16.7%

24.0%

21.3%

7.3%

11.3%

21.3%

14.7%

17.3%

12.0%

9.3%

24.7%

60.8%

47.4%

44.3%

25.8%

4.1%

19.6%

24.7%

54.6%

56.7%

9.3%

16.8%

38.9%

44.2%

28.3%

26.5%

21.2%

9.7%

34.5%

23.9%

27.4%

16.8%

0% 50% 100% 150% 200% 250%

Carer Relationship

Life after stroke

Cognition

Mood

Communication

Continence

Pain

Spasticity

Mobility

Activities of daily living

Absence of secondary prevention

Italy UK Singapore China Australia

Iosa et al., 2017 ; Ward et al., 2014

Italy (n=64), UK (42), Singapore (100), China (97),

Australia (113). Spectrum of long term issues post stroke across 5 countries

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11.5%

11.5%

23.0%

29.5%

23.8%

36.1%

36.9%

41.0%

51.6%

36.9%

16.4%

23.0%

23.0%

27.9%

29.5%

41.0%

50.8%

50.8%

55.7%

*59.0%

60% 40% 20% 0% 20% 40% 60%

INCONTINENCE

PAIN

RELATIONSHIP WITH FAMILY STRESSES

SPASTICITY

COMMUNICATION DIFFICULTIES

MOOD

MOBILITY LIMITATIONS

ACTVITIES OF DAILY LIVING DIFFICULTIES

LIFE LIMITATIONS (WORK, HOBBIES)

COGNITIVE DIFFICULTIES

Female

Male

Frequency of Persisting Problems by Gender Results

Overall 82.5% patients reported at least one deficit at 6 months; with a higher incidence amongst females (86.9%) compared to males (80.3%) (non-significant)

The top 5 symptoms were the same for males and females but the number affected were different (greater in females)

Persisting Problems by Gender Results

Females reported significantly more cognitive difficulties than males (59.0% to 36.9%, *p<0.01)

Females are over twice as likely to report persisting cognitive difficulties at six months post stroke (Odds Ratio: 2.46, 95% Confidence Interval (CI) = 1.31 - 4.62)

Females also reported increased mobility limitations (50.8% to 36.9%), pain (23.0% to 11.5% - trending towards significance; p=.070), difficulties performing activities of daily living (50.8% to 41.0%) and communication difficulties (29.5% to 23.8%)

Cognition was the only significant predictor of symptom presentation differentiating between females and males

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Conclusion

Without a lot of modification, this checklist can be

trialled as a PROM for TBI

Epworth Monash Rehabilitation Medicine Unit Research Team

Thank you

Email: john.olver@epworth.org.au