Diffuse Damage

The diffuse nature of TBI has resulted in a constel­lation of motor impairments that is familiar to clini­cians who work with these problems. These include difficulties with balance, coordination, and speed of response.

Swaine and Sullivan (66) have examined early motor recovery after TBI in 16 adolescents and adults who had a GCS score of 8 or lower for at least 6 hours. Assessments included evaluation of muscle tone, range of motion, abnormal and voluntary movement, prim­itive reflexes, equilibrium and protective responses, and specific motor skills. There were differential pat­terns of recovery and differential rates of recovery among the subjects, which is to be expected consider­ing the heterogeneous nature of TBI.

Chaplin and colleagues (67) evaluated motor per­formance in children after TBI. Fourteen children with TBI who were unconscious for 24 hours or longer were compared with 14 age- and sex-matched children. The Bruininks-Oseretsky Test of Motor Proficiency was administered at least 16 months after injury. Children with TBI scored significantly poorer on the Gross Motor Composite, including all subsets: running speed, bal­ance, bilateral coordination, and strength. Also, they scored lower on the fine motor subsets for upper limb speed and dexterity. Most of these subtests involve timed tasks. Chaplin and colleagues also found a cor­relation between the Gross Motor Composite score and the time since injury. They concluded that this corre­lation supports continuing long-term improvement in skills after TBI.

Kuhtz-Buschbeck and colleagues (68) looked at gait, gross motor proficiency, and hand function in 23 children after a TBI, severe in 17 and moderate in 6, during their five months of inpatient stay. They were compared with age- and sex-matched healthy controls. Children with TBI showed marked reduction in gait velocity, stride length, cadence, and balance. Deficits in fine motor skills, speed, and coordination were noted on hand function tests. Hand function skills improved less than gait; degree of impairment was noted to increase with severity of injury. Younger age at injury was not associated with better recovery. It has also been noted that the absence of spasticity is a good predictor of ambulation recovery by discharge (69,70).

Others have also noted impaired fine motor skills after TBI. Again, the speed component of the assess­ment on these tasks may account for some of the impairments that were observed. Long-term impair­ment of finger tapping has been described (71). Practice of activities requiring fine motor coordination improves skills, even long after injury (72).