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The Glasgow Outcome Scale (GOS) was first published in 1975 by Bryan Jennett and Michael Bond. With over 4,000 citations to the original paper, it is the most highly cited outcome measure in studies of brain injury and the second most-cited paper in clinical neurosurgery. The original GOS and the subsequently developed extended GOS (GOSE) are recommended by several national bodies as the outcome measure for major trauma and for head injury. The enduring appeal of the GOS is linked to its simplicity, short administration time, reliability and validity, stability, flexibility of administration (face-to-face, over the telephone and by post), cost-free availability and ease of access. These benefits apply to other derivatives of the scale, including the Glasgow Outcome at Discharge Scale (GODS) and the GOS paediatric revision. The GOS was devised to provide an overview of outcome and to focus on social recovery. Since the initial development of the GOS, there has been an increasing focus on the multidimensional nature of outcome after head injury. This Review charts the development of the GOS, its refinement and usage over the past 40 years, and considers its current and future roles in developing an understanding of brain injury.

Background: Traumatic Brain Injury (TBI) is an important global public health problem made all the more important by the increased likelihood of disability following a hospital admission for TBI. Understanding those groups most at risk will help inform interventions designed to prevent causes of TBI, such as falls prevention measures. This study identifies the rate of hospitalisation episodes of TBI in Scotland, explores causes of TBI admissions, and trends in hospitalisation episodes by age and gender over a twelve year period using routinely collected hospital data., Methods: A retrospective analysis of routine hospital episode data identified records relating to TBI for the twelve years between 1998 and 2009. Descriptive and joinpoint regression analysis were used, average annual percentage changes (AAPC) and annual percentage change (APC) in rates were calculated., Results: Between 1998 and 2009 there were 208,195 recorded episodes of continuous hospital care in Scotland as a result of TBI. Almost half (47%) of all TBIs were the result of falls, with marked peaks observed in the very young and the oldest groups. The AAPC of hospitalization episode rates over the study period for boys and girls aged 0-14 were -4.9% (95% CI -3.5 to-6.3) and -4.7% (95% CI -2.6 to -6.8) respectively. This reduction was not observed in older age groups. In women aged 65 and over there was an APC of 3.9% (95% CI 1.2 to 6.6) between 2004 and 2009., Conclusions: Hospitalisation for TBI is relatively common in Scotland. The rise in the age-adjusted rate of hospitalisation episodes observed in older people indicates that reduction of TBI should be a public health priority in countries with an ageing population. Public health interventions such as falls prevention measures are well advised and evaluations of such interventions should consider including TBI hospitalisation as an alternative or supplementary outcome measure to fractured neck of femur. Further research is needed to advance understanding of the associations of risk factors with increased incidence of TBI hospital episodes in the elderly population.

Background: The evidence base on neurobehavioural disorders and their rehabilitation has been growing for four decades. Over that time understanding of the need for effective interventions for a range of handicaps in personal, interpersonal and employment spheres has developed. There is a continuing need to demonstrate whether interventions, are effective and cost-sensitive. Moreover, in pursuing effectiveness, clinicians need to be able to predict which individuals are likely to benefit from a programme and here, clinical experience needs to be informed by research evidence., Objective: To review the outcome of rehabilitation for neurobehavioural disorders., Methods: This review initially considers the background to neurobehavioural rehabilitation and discusses methodological issues. It reviews the evidence for neurobehavioural interventions for severe head injury with emphasis on holistic models of care, behavioural treatments, interventions in non-specialist settings and for emotion perception and self-awareness., Results: In general, there is a need for further high quality studies with longer follow-ups and evidence for generalisation in the community. However, there is a growing consensus that intensive holistic rehabilitation programmes can improve community reintegration and self-efficacy. For behaviour disturbance the evidence base largely comprises studies with weaker (single group or single case) designs. Overall studies here provide limited evidence in support of behavioural approaches for externalised behaviour such as aggression. Further RCT or group comparison studies are needed. In terms of negative behaviours such as apathy, there are few studies on head injury and conclusions cannot be made with confidence. Self awareness is a key issue associated with good outcome in general and research to date supports use of interventions that focus in on-task behaviour and education. The correct perception of emotions in others is a precursor to successful social interaction, and here there is very little evidence although early studies are encouraging., Conclusion: There is mounting evidence to support the effectiveness of non-pharmacological interventions for neurobehavioural disorders. Successful outcomes are often associated with intensive and prolonged interventions involving multidisciplinary working.

Aim: It is now generally accepted that paediatric acquired brain injury (ABI) can have an impact on a child's cognitive, social, and behavioural functioning. However, the lack of guidelines on effective interventions for the affected children and their families, particularly beyond the acute recovery phase, can limit access to effective support. We provide a systematic review of the literature on the effectiveness of psychological interventions aimed at alleviating cognitive and psychosocial outcomes after paediatric ABI., Method: The search used the Ovid MEDLINE, Embase, Web of Knowledge, and EBSCO databases and hand searches of key journals. Nine studies met inclusion criteria: five intervention studies of cognitive outcome and four of psychosocial outcome. Effect sizes and methodological quality ratings were calculated using specific criteria., Results: Only two of the nine studies were rated as high quality. There was limited evidence for effective interventions for cognitive outcomes (attention, memory, and learning difficulties). For psychosocial outcomes, there was evidence that interventions can alleviate internalizing symptoms., Interpretation: Although there are some encouraging findings, there is a need for further, more rigorously designed, and better controlled research in this important area. We discuss how future research may consider issues such as age-appropriate interventions, the delivery format, and optimum post-injury timing of interventions, as well as multicentre collaborations., (© The Authors. Developmental Medicine & Child Neurology © 2011 Mac Keith Press.)

Objective: This study compares friendship quality, rates of loneliness and general psychosocial functioning in children who have sustained a traumatic brain injury (TBI) with non-injured controls., Methods: A between-subjects design with 14 participants in the TBI group and 14 in the non-injured control group, aged between 7-13 years and matched for age, gender, receptive vocabulary and socio-economic status. Children completed measures of receptive vocabulary (BPVS II), friendship quality (FQQ-R) and loneliness (LSDS). The main caregiver was asked to assess social skills and social withdrawal (PIC-2) and general psychosocial and behavioural functioning (SDQ)., Results: Significant differences were not found on measures completed by children or on the PIC-2. On the SDQ, total difficulties were rated as much greater by caregivers in the TBI group (z = -2.6, p = 0.009) and these were mainly associated with sub-scales relating to emotional problems and hyperactivity., Conclusions: Whilst evidence for friendship problems was not found in children with TBI, evidence for emotional and behavioural difficulties that may lead to social vulnerabilities later in life were found. This indicates a need for prospective longitudinal research to explore the complex relationship between TBI and poorer social outcomes that may not become evident until adolescence.

Objective: To examine objective and subjective reports of sleep disturbance in school-aged children who had sustained mild traumatic brain injury (TBI) at least 6 months prior to the study., Methods: Eighteen children aged 7-12 years with a history of mild TBI (GCS 13-15. LOC < 15 min) were compared to 30 children with orthopedic injuries using actigraphy and parental and self-report sleep questionnaires., Results: Parents reported greater sleep disturbance in the mild TBI group. No significant differences were found in parental ratings of daytime sleepiness, child-reported sleep difficulties, or objective (actigraph) sleep measures., Conclusions: The finding of greater parental reports of sleep disturbance following mild TBI 6 months after injury requires greater exploration and future research with a larger sample followed from the point of injury would seem appropriate.

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury., (Copyright 2004 Taylor and Francis Ltd)

Objective: To survey the characteristics, level of disability and services received by young adults with acquired brain injury (ABI) resident in nursing homes in Greater Glasgow., Design: Telephone survey of 75 nursing homes followed by a questionnaire survey and review of medication cardexes. Included were all people under 65 years with ABI resident in nursing homes in Greater Glasgow between 1 February 2000 and 31 January 2001., Setting: Twenty-eight nursing homes in Greater Glasgow, Scotland (population 0.9 million)., Subjects: Young adults (16-64) with ABI., Main Outcome Measures: Structured questionnaire, Barthel Index, Office of Population Census Survey (OPCS) Disability Form, review of medication cardexes., Results: Information was obtained on all cases identified in 75 nursing homes. There were 92 people with ABI in 28 nursing homes; 43/92 were in three homes. Only 42 had inpatient rehabilitation preadmission. Severe disability (OPCS categories 7-10) was found in 54 cases and minimal/minor disability (OPCS categories 1-2) in 18. Thirty-two exhibited challenging behaviour, nine of these were physically violent. Homes were staffed by unqualified assistants, supervised by nurses. No home itself offered rehabilitation, but some had accessed an NHS physical disability community team (28/92 cases) or other community teams (5/92). Proactive medical review was uncommon. Medication had been reviewed since admission in a minority (21/92). Most had regular visits from relatives., Conclusions: There is a wide range of disability in nursing home residents in Greater Glasgow. Proactive, routine review of medical, rehabilitation and medication needs is rare, as is rehabilitation pre and post discharge. This is serious given the likelihood of reduced intellectual and/or physical capacity in this population. Nursing homes should have hospital discharge reports that inform about immediate preadmission history, rationale for medication and placement. There is a need for regular and ongoing health service review of nursing home residents including potential for rehabilitation and return to community living.

Objective: To survey the role, function and staffing of community rehabilitation teams in London and the South East NHS Region of England who work with neurologically disabled people, with emphasis on services provided for traumatic brain injury., Design: Telephone survey using a structured interview with team leaders., Setting: London and South East NHS Regions of England (population 15.6 million)., Subjects: Community rehabilitation teams., Main Outcome Measures: A structured interview about service provision., Results: Thirty-five teams were found in 25 Health Authorities serving 14 million people. In a further five Health Authorities, another five teams did not participate. There were fewer than 1.5 community team professionals for 4,000-5,000 neurologically disabled. Teams had seen less than 3% of disabled traumatic brain injuries. Most focused on physical disability. Only two teams specialized in consequences of cognitive impairment or personality change. Stroke and multiple sclerosis were the most common referrals. Sixty per cent of teams had no clinical psychologist. The composition of teams is described, as is caseload, clinical role, outcome measures used, professional links, work practice and staffing issues., Conclusions: Community physical disability teams seem insufficiently resourced to provide a comprehensive service for the neurologically disabled. There are not enough teams generally, and too few specialize in psychosocial problems. All teams should include a clinical psychologist, should have specialist resources for cases from ethnic minorities and formal policies for staff security. There needs to be clarity over the range of services provided and to whom, and this linked to prevalence of disability and team resourcing.

Evidence to support the view that post-traumatic stress disorder (PTSD) can occur after traumatic brain injury (TBI) continues to grow. However, the reported incidence of cases with both diagnoses ranges widely, from less than 1% to more than 50%. Given that the incidence of TBI is high, a more precise incidence has to be established if screening and treatment resources are to be considered. Are cases being missed or are they over-diagnosed? The single case report presented here does not definitively answer this question, but illustrates the potential shortcomings of diagnosing PTSD using questionnaire measures alone (Impact of Events Scale, Post-traumatic Stress Diagnostic Scale and General Health Questionnaire) and indicates a need for a conjoint interview which takes into account the common effects of TBI and the symptom overlap between PTSD and TBI.

A systematic neuropsychological assessment technique is described for use with severely physically disabled people who may be severely brain-damaged, in an incomplete locked-in state or potentially in vegetative state. The technique allows opinions regarding cognitive state to be statistically based. In the case described, the weight of expert opinion had been that involuntary feeding by gastrostomy tube should be terminated because the patient was functioning at a level little beyond the vegetative state, her quality of life was poor and she was unable to form a view about her present or future circumstances. An assessment approach is described which uses binomial statistics and allows for some variability in responding. Methods of minimizing sources of extraneous bias are also discussed. By use of this technique it was demonstrated that the patient was sentient though impaired, and that her own wish at the time of the assessment was to continue living. It is recommended that neuropsycholgical assessment of this kind should take place in all cases in which withdrawal of treatment is being considered and cognitive ability is not certain.

Post-traumatic stress disorder (PTSD) is described following a road traffic accident in which the patient suffered a severe head injury. The stress reaction was associated with intrusive thoughts and avoidance of cognitive and physical events associated with consequences of the accident. The condition was successfully treated by behavioural intervention. It seems clear that PTSD can occur even where there is loss of consciousness and organic amnesia for the event and its immediate sequelae.

There is a growing awareness of deficits in service provision for severely head-injured patients. This study identifies areas in which patients fail to receive services by investigating the admission and transfer of such patients from eleven District Health Authorities in North London and the services offered by rehabilitation professionals in hospital and community. Sixty per cent of our sample were referred to Neurosurgical Units (NSUs) and later transferred to District General Hospitals (DGHs). Of these, 20% remained in DGHs without receiving NSU care, while 20% were treated at NSUs but were not referred to a local DGH. Assessment of rehabilitation services revealed that on average physiotherapists offered the greatest amount of therapy time to head-injured patients (3-4 hours) per week compared with other professionals and that this seemed to be a reflection of referral systems. Of the patients in our sample approximately 80% received physiotherapy, 30% received occupational therapy and less than 15% received speech therapy, social work or clinical psychology. It was concluded that severely head-injured patients fail to receive available services due to haphazard admission and transfer procedures, lack of referral to rehabilitation professionals and to the paucity of appropriate community care.

Background: There is continuing concern about effects of concussion in athletes, including risk of the neurodegenerative disease chronic traumatic encephalopathy. However, information on long-term health and wellbeing in former athletes is limited.Method: Outcome after exposure to repeated brain injury was investigated in 52 retired male Scottish international rugby players (RIRP) and 29 male controls who were similar in age and social deprivation. Assessment included history of playing rugby and traumatic brain injury, general and mental health, life stress, concussion symptoms, cognitive function, disability and markers of chronic stress (allostatic load).Results: The estimated number of concussions in RIRP averaged 14 (median=7; IQR 5-40). Performance was poorer in RIRP than controls on a test of verbal learning (p=0.022) and of fine co-ordination of the dominant hand (p=0.038) and not significantly different on other cognitive tests (p>0.05). There were no significant associations between number of concussions and performance on cognitive tests. Other than a higher incidence of cardiovascular disease in controls, no group differences were detected in general or mental health or estimates of allostatic load. In RIRP, persisting symptoms attributed to concussion were more common if reporting more than nine concussions (p=0.028), although these symptoms were not perceived to affect social or work functioning.Conclusions: Despite a high number of concussions in RIRP, differences in mental health, social or work functioning were not found late after injury. Subtle group differences were detected on two cognitive tests, the cause of which is uncertain. Prospective group comparison studies on representative cohorts are required. [ABSTRACT FROM AUTHOR]

Background Head injury is common, and the risk of subsequent disability and death is high. Increased risk of death years after injury might be explained by factors associated with, but not a consequence of, the head injury. This unique prospective study investigates mortality over 13 years after injury. Methods A cohort of n=767 with head injury was compared with two case control groups, matched for age, gender and deprivation, and in one control group, matched for duration of hospital admission following (non-head) injury. Results Two-fifths of the head injury cohort had died. The death rate (30.99 per 1000 per year) was much higher than in community controls (13.72 per 1000 per year). More than 1 year after injury, the death rate in younger (15-54 years) adults was much higher than in community controls (17.36 vs 2.36 per 1000 per year) whereas in older adults the difference was more marginal (61.47 vs 42.36). Death rate was elevated after mild and after more severe head injury, including in younger adults after mild head injury (14.82 per 1000 per year mild head injury vs 2.21 community). Female gender and greater deprivation were not associated with increased death rates after head injury. Late after injury, deaths occurred from the same main causes as for the general population. Conclusion Head injury is associated with increased vulnerability to death from a variety of causes for at least 13 years after hospital admission. There is a need to understand how head injury influences mortality, particularly in younger adults and after mild head injury. [ABSTRACT FROM AUTHOR]

Objective: Can the concept of 'partial' PTSD explain the disparity between the relatively high incidence of PTSD found using self-report questionnaires and the relatively low incidence using structured interview? It was hypothesized that self-report of greater PTSD symptom severity is associated with increased heart rate and movement when responding to questions about the traumatic event, if 'partial' PTSD is an explanation. Research design: A within participants single group design. Methods: Twenty-one adults with head injury underwent self-report (Post-traumatic Stress Disorder Scale) and interview (Clinical Assessment of PTSD) assessments of PTSD, the Traumatic Memory Interview, self-report of mood (Hospital Anxiety and Depression Scale) and cognitive assessment (Wechsler Test of Adult Reading, Auditory Verbal Learning Test, Hayling Test, Digit Symbol Test), during which heart rate and motor activity were recorded. Results: Self-report of greater PTSD symptom severity was not associated with increases in heart rate or movement during questions about the traumatic event. In fact, heart rate decreased from baseline in those with higher self-report scores for PTSD, consistent with curiosity about the traumatic event and not 'partial' PTSD. Conclusion: These preliminary findings agree with an emerging theme suggesting that, although PTSD can occur after head injury, it is easily over-diagnosed. [ABSTRACT FROM AUTHOR]

Objective To examine objective and subjective reports of sleep disturbance in school-aged children who had sustained mild traumatic brain injury (TBI) at least 6 months prior to the study. Methods Eighteen children aged 7-12 years with a history of mild TBI (GCS 13-15. LOC < 15 min) were compared to 30 children with orthopedic injuries using actigraphy and parental and self-report sleep questionnaires. Results Parents reported greater sleep disturbance in the mild TBI group. No significant differences were found in parental ratings of daytime sleepiness, child-reported sleep difficulties, or objective (actigraph) sleep measures. Conclusions The finding of greater parental reports of sleep disturbance following mild TBI 6 months after injury requires greater exploration and future research with a larger sample followed from the point of injury would seem appropriate. [ABSTRACT FROM AUTHOR]

Assessing PTSD by questionnaire can lead to false positive diagnosis after severe traumatic brain injury. Sumpter and McMillan, reported quantitative data on 34 people with severe TBI; 59% were PTSD ‘cases’ by questionnaire assessment, but only 3% using a structured interview. The present paper describes ways in which these individuals made errors on questionnaires. Some did not follow questionnaire instructions because of inattention and concrete thinking or instead reported effects of brain injury. Symptom overlap between TBI and PTSD, including insomnia, irritability and impaired concentration can cause errors. Brain injury can also provoke curiosity about loss of memory (during coma, retrograde and post-traumatic amnesia), decreased participation, social withdrawal and difficulty adjusting to injury that may be mistaken for fear-associated PTSD symptoms. Assessment of PTSD by questionnaire can lead to erroneous conclusions and factors related to brain injury must be carefully considered when investigating PTSD. [ABSTRACT FROM AUTHOR]

Objective: To compare opinion about post-concussion syndrome (PCS) in accident and emergency doctors, clinical neuropsychologists and neurosurgeons. Method: A UK postal survey was sent to all accident and emergency doctors, neurosurgeons and clinical neuropsychologists listed by their professional bodies. Predictions of symptom complaint were made from a vignette about minor traumatic brain injury and a questionnaire about PCS-symptoms, cause, recovery and treatment. Results: All professional groups named headache, attention and memory difficulties as most common symptoms. Clinical neuropsychologists listed more symptoms at recall, more often achieved 'caseness' (Diagnostic and Statistical Manual-IV or International Classification of Diseases-10 criteria) and were more optimistic about treatment effectiveness. Neurosurgeons were more pessimistic about recovery. Organic factors were most frequently cited as the main cause of PCS, followed by emotional factors and then compensation factors. Conclusions: There was fair consistency between professional groups regarding PCS. Differences may reflect differing clinical roles between the professions, in terms of early care and late rehabilitation. The usefulness of the concept of PCS is discussed. All groups and particularly those working in acute settings may benefit from further information about minor brain injury including the effectiveness of psychological interventions. [ABSTRACT FROM AUTHOR]

Background. Expectations about effects of minor traumatic brain injury (MTBI) may play a role in maintaining symptoms, the ability to simulate post-concussion syndrome (PCS) and the extent to which professionals might associate patient complaints with MTBI. In turn, expectations will be related to knowledge about MTBI. This study investigates knowledge of PCS in people with MTBI compared with general practitioners (GPs) and lay-people, using recall (a vignette) and symptom guessing or recognition (checklists). Methods. Thirty GPs, 30 people with MTBI, and 30 lay-people generated symptoms from a vignette describing a MTBI. They then completed a PCS checklist or a checklist containing PCS and 'bogus' items pertaining to the vignette. Results. Only 1 of 90 participants reported enough PCS symptoms to indicate 'caseness' from the vignette alone. Using checklists, more GPs (60%) than controls (20%) ticked enough symptoms to attain PCS 'caseness'. Few people with MTBI who did not themselves achieve PCS 'caseness' by self-report using checklists achieved 'caseness' using the vignette and checklists. The frequency of non-physical symptom reporting was higher than for physical symptom reporting. The addition of 'bogus' items to checklists did not affect responding. Conclusions. It is unlikely that pre-injury expectations about MTBI maintain PCS symptoms. PCS was difficult to simulate without prompting, even by GPs and PCS 'cases'. The use of 'caseness', rather than simple symptom scores, and further development of checklists with 'bogus' items may provide a more valid assessment of MTBI effects. GPs may benefit from further information about PCS and available treatments. [ABSTRACT FROM AUTHOR]