Journey to 1 Million Steps: A Retrospective Case Series Analyzing the Implementation of Robotic-Assisted Gait Training Into an Outpatient Pediatric Clinic.

PURPOSE: To describe the implementation of an exoskeleton program in a rehabilitation setting using a Design Thinking framework. METHODS: This is a retrospective case series of 3 randomly selected children who participated in skilled physical therapy using a pediatric exoskeleton that occurred on our journey to walking 1 000 000 steps in the exoskeleton devices. Participants ranged in age from 3 to 5 years, and all had neurologic disorders. RESULTS: All participants improved toward achieving their therapy goals, tolerated the exoskeleton well, and had an increased number of steps taken over time. CONCLUSION: The implementation of new technology into pediatric care and an established outpatient therapy clinic is described. The Design Thinking process applies to health care professionals and improves clinical care. Exoskeletons are effective tools for use in pediatric physical therapy.

Thalamic deep brain stimulation in traumatic brain injury: a phase 1, randomized feasibility study.

Converging evidence indicates that impairments in executive function and information-processing speed limit quality of life and social reentry after moderate-to-severe traumatic brain injury (msTBI). These deficits reflect dysfunction of frontostriatal networks for which the central lateral (CL) nucleus of the thalamus is a critical node. The primary objective of this feasibility study was to test the safety and efficacy of deep brain stimulation within the CL and the associated medial dorsal tegmental (CL/DTTm) tract.Six participants with msTBI, who were between 3 and 18 years post-injury, underwent surgery with electrode placement guided by imaging and subject-specific biophysical modeling to predict activation of the CL/DTTm tract. The primary efficacy measure was improvement in executive control indexed by processing speed on part B of the trail-making test.All six participants were safely implanted. Five participants completed the study and one was withdrawn for protocol non-compliance. Processing speed on part B of the trail-making test improved 15% to 52% from baseline, exceeding the 10% benchmark for improvement in all five cases.CL/DTTm deep brain stimulation can be safely applied and may improve executive control in patients with msTBI who are in the chronic phase of recovery.ClinicalTrials.gov identifier: NCT02881151 .

Evolution of rehabilitation services in response to a global pandemic: reflection on opportunities and challenges ahead.

The rapidly evolving COVID-19 public health emergency has disrupted and challenged traditional healthcare, rehabilitation services, and treatment delivery worldwide. This perspective paper aimed to unite experiences and perspectives from an international group of rehabilitation providers while reflecting on the lessons learned from the challenges and opportunities raised during the COVID-19 pandemic. We discuss the global appreciation for rehabilitation services and changes in access to healthcare, including virtual, home-based rehabilitation, and long-term care rehabilitation. We illustrate lessons learned by highlighting successful rehabilitation approaches from the US, Belgium, and Japan.

Psychosocial Impacts of the COVID-19 Quarantine: A Study of Gender Differences in 59 Countries.

Background and Objectives: There is strong evidence in the literature that women experience psychological disorders at significantly higher rates than men. The higher rates of psychological disorders in women may partly be attributable to gender differences in response to stressors and coping styles. The objective of this study was to contribute to the growing body of literature investigating gender differences in mental health outcomes and coping styles during the coronavirus disease 2019 pandemic in a large sample of individuals from 59 countries with variable demographic and socio-cultural characteristics. Materials and Methods: Survey data were collected from the general population following a snowball sampling method, and the survey was promoted through social media platforms and mailing lists. Participants included 6882 individuals from the general population from 59 countries around the world. A combination of both standardized and adapted measures was used to create a survey, originally in English and then translated to Spanish, Italian, French, German, and Turkish. Results: Compared with men, women presented with higher levels of trauma-related distress; had a harder time decompressing; were more depressed, anxious and stressed; showed decreased frustration tolerance and reported lower quality of sleep and an increased likelihood of taking sleep medication or other natural sleep remedies. Overall, women tended to be more vulnerable during the pandemic in developing symptoms consistent with various forms of mental disorders such as depression, anxiety and post-traumatic distress. However, they also were more likely than men to use a variety of adaptive coping strategies, including concentrating on doing something about the situation and getting emotional support from others. Conclusions: A high prevalence of mood symptoms was noted among women. In addition to meeting the physical health needs of the population, emphasis needs to be given to mental health and the prevention of psychiatric disorders, particularly in women.

Relationship of patient characteristics and inpatient rehabilitation services to 5-year outcomes following spinal cord injury: A follow up of the SCIRehab project.

OBJECTIVE: To examine associations of patient characteristics and treatment quantity delivered during inpatient spinal cord injury (SCI) rehabilitation with outcomes at 5 years post-injury and compare them to the associations found at 1 year post-injury. DESIGN: Observational study using Practice-Based Evidence research methodology in which clinicians documented treatment details. Regression modeling was used to predict outcomes. SETTING: Five inpatient SCI rehabilitation centers in the US. PARTICIPANTS: Participants were 792 SCIRehab participants who were >12 years of age, gave informed consent, and completed both a 1-year and 5-year post-injury interview. OUTCOME MEASURES: Outcome data were derived from Spinal Cord Injury Model Systems (SCIMS) follow-up interviews at 5 years post-injury and, similar to the 1-year SCIMS outcomes, included measures of physical independence, societal participation, life satisfaction, and depressive symptoms, as well as place of residence, school/work attendance, rehospitalization, and presence of pressure ulcers. RESULTS: Consistent with 1-year findings, patient characteristics continue to be strong predictors of outcomes 5-years post-injury, although several variables add to the prediction of some of the outcomes. More time in physical therapy and therapeutic recreation were positive predictors of 1-year outcomes, which held less true at 5 years. Greater time spent with psychology and social work/case management predicted greater depressive symptomatology 5-years post-injury. Greater clinician experience was a predictor at both 1- and 5 -years, although the related positive outcomes varied across years. CONCLUSION: Various outcomes 5-years post-injury were primarily explained by pre-and post-injury characteristics, with little additional variance offered by the quantity of treatment received during inpatient rehabilitation.

Sex and Gender Issues for Individuals With Acquired Brain Injury During COVID-19: A Commentary.

Worldwide, the rehabilitation community has been affected by coronavirus disease 2019 (COVID-19). The effect of COVID-19 has been disproportionately devastating for individuals with disabilities, particularly those with acquired brain injury (ABI) owing to injury-related cognitive or sensory and physical difficulties. Many physical and psychological symptoms of COVID-19 are already well-known issues for individuals with ABI. Even in a fully functional social and health care system, post-ABI deficits can pose greater challenges to women and other marginalized groups, such as lesbian, gay, bisexual, transgender, gender-nonconforming, and queer or questioning-identified individuals. The restrictions and changes brought about by COVID-19 have the potential to broaden the existing disparities and limitations. This commentary highlights 3 key areas to attend to during this pandemic to help assuage such disparities and limitations.

The Effects of Early Mobilization on Patients Requiring Extended Mechanical Ventilation Across Multiple ICUs.

OBJECTIVES: 1) To successfully implement early mobilization of individuals with prolonged mechanical ventilation in multiple ICUs at a tertiary care hospital and 2) to reduce length of stay and improve quality of care to individuals in the ICUs. DESIGN: Comparative effectiveness cohort study based on a quality improvement project. SETTING: Five ICUs at a tertiary care hospital. PATIENTS: A total of 541 mechanically ventilated patients over a 2-year period (2014-2015): 280 and 261, respectively. Age ranged from 19 to 94 years (mean, 63.84; sd, 14.96). INTERVENTIONS: A hospital-based initiative spurred development of a multidisciplinary team, tasked with establishing early mobilization in ICUs. MEASUREMENTS AND MAIN RESULTS: Early mobilization in the ICUs was evaluated by the number of physical therapy consults, length of stay, individual treatment sessions utilizing functional outcomes, and follow-up visits. Implementation of an early mobilization protocol across all ICUs led to a significant increase in the number of physical therapy consults, a significant decrease in ICU and overall lengths of stay, significantly shorter days to implement physical therapy, and a significantly higher physical therapy follow-up rate. CONCLUSIONS: Mobilizing individuals in an intensive care setting decreases length of stay and hospital costs. With an interdisciplinary team to plan, implement, and evaluate stages of the program, a successful early mobilization program can be implemented across all ICUs simultaneously and affect change in patients who will require prolonged mechanical ventilation.

An interview based approach to the anorectal portion of the International Standards of Neurological Classification of Spinal Cord Injury Exam (I-A-ISNCSCI): a pilot study.

STUDY DESIGN: Prospective, single-blinded study. OBJECTIVE: To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. SETTING: AIR unit. METHODS: Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. RESULTS: Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52-0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48-0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53-1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47-0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI -0.01 to 0.59, N = 36). Responses of "I don't know" were excluded from agreement analyses. CONCLUSIONS: This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.

Factors associated with the remission of insomnia after traumatic brain injury: a traumatic brain injury model systems study.

Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point.Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21).Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found.Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors.

Measuring Fatigue in TBI: Development of the TBI-QOL Fatigue Item Bank and Short Form.

OBJECTIVE: To develop a traumatic brain injury (TBI)-specific, item response theory (IRT)-calibrated Fatigue item bank, short form, and computer adaptive test (CAT) as part of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system. SETTING: Five TBI Model Systems rehabilitation centers in the US PARTICIPANTS:: Adults with complicated mild, moderate, or severe TBI confirmed by medical record review. DESIGN: Cross-sectional field testing via phone or in-person interview. MAIN MEASURES: TBI-QOL Fatigue item bank, short form, and CAT. RESULTS: A total of 590 adults with TBI completed 95 preliminary fatigue items, including 86 items from the Patient-Reported Outcomes Measurement Information System (PROMIS) and 9 items from the Quality of Life in Neurological Disorders (Neuro-QOL) system. Through 4 iterations of factor analysis, 22 items were deleted for reasons such as local item dependence, misfit, and low item-total correlations. Graded response model IRT analyses were conducted on the 73-item set, and Stocking-Lord equating was used to transform the item parameters to the PROMIS (general population) metric. A short form and CAT, which demonstrate similar reliability to the full item bank, were developed. Test-retest reliability of the CAT was established in an independent sample (Pearson's r and intraclass correlation coefficient = 0.82 [95% confidence interval: 0.72-0.88]). CONCLUSIONS: The TBI-QOL Fatigue item bank, short form, and CAT provide rehabilitation researchers and clinicians with TBI-optimized tools for assessment of the patient-reported experience and impact of fatigue on individuals with TBI.

Associations Between Insurance Provider and Assistive Technology Use for Computer and Electronic Devices 1 Year After Tetraplegia: Findings From the Spinal Cord Injury Model Systems National Database.

OBJECTIVE: To investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. DESIGN: Multicenter cross-sectional study. SETTING: Participants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. INTERVENTIONS: Not applicable. PARTICIPANTS: Men and women with tetraplegia (N=498) enrolled in the SCIMS National Database were included in the analysis. MAIN OUTCOME MEASURES: The primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject's principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers' compensation. RESULTS: Overall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers' compensation were more likely to report AT use than individuals with either government or private insurance. CONCLUSIONS: Despite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers' compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.

Outcome prediction from post-injury resilience in patients with TBI.

PURPOSE/OBJECTIVE: The objective of the study was to evaluate the extent to which 1- and 2-year outcomes after traumatic brain injury (TBI) are predicted by resilience. Research Method/Design: This was an observational, longitudinal study of persons (n = 158) with moderate or severe TBI who completed both 1- and 2-year outcome assessments. Outcomes included anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), life satisfaction (Satisfaction with Life Scale), substance misuse, and return-to-work measures. The Connor-Davidson Resilience Scale was used to assess resilience at 3 or 6 months after injury. RESULTS: Greater resilience predicted less anxiety, depression, and substance use and better satisfaction with life and return to work at 1 year after injury for both adjusted and unadjusted models. Standardized regression coefficients were all greater than 0.38 for continuous outcomes, whereas odds ratios were 1.34 and 0.81 for the return to work and substance misuse outcomes, respectively (p < .05). Similar but weaker trends were found at 2 years after injury, with statistical significance no longer met for all outcomes. CONCLUSIONS/IMPLICATIONS: Resilience was shown to have predictive ability for outcomes at 1 and 2 years after TBI. Resilience appears to be a salient and important variable for long-term outcomes in person with TBI after adjusting for injury and demographic characteristics. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis.

BACKGROUND: Data evaluating the role of exercise in patients with a concussion are contradictory. Studies have reported improvement in the Post-Concussion Symptom Scale (PCSS) score, whereas others showed no effect on the PCSS score. PURPOSE: To conduct a systematic review and meta-analysis on the role of physical exercise on different outcomes in patients with a concussion. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A search of 5 databases from the earliest available date to September 30, 2016, and a hand search of a few articles were performed. Trial registries were reviewed, and authors of multiple studies were contacted to find additional published or unpublished studies. Randomized controlled trials (RCTs), cohort studies, and before and after (pre-post) studies evaluating the effect of physical exercise, compared with control, in patients with a concussion or mild traumatic brain injury were included. RESULTS: The search generated 1096 studies. Of these, 14 studies (5 RCTs, 1 propensity score matching study, 3 cohort studies, and 5 before and after studies) met our inclusion criteria. Exercise significantly decreased the PCSS score (mean difference, -13.06; 95% CI, -16.57 to -9.55; P < .00001; I2 = 44%), percentage of patients with symptoms of a concussion (risk ratio, 0.74; 95% CI, 0.63 to 0.86; P = .0001; I2 = 0%), and days off work (17.7 days vs 32.2 days, respectively; P < .05) compared with control. Exercise improved the reaction time (standard mean difference, -0.43; 95% CI, -0.80 to -0.06; P = .02) component of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) score without affecting the Balance Error Scoring System (BESS) score and neuropsychological parameters. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) scores were moderate for the PCSS, symptoms, ImPACT, BESS, and neuropsychological tests. CONCLUSION: Physical exercise appears to improve the PCSS score and symptoms in patients with a concussion. A high-quality RCT evaluating different intensities of exercise at different time points, for different durations after a concussion, for different races/ethnicities, and for sex needs to be conducted to evaluate a clear effect of exercise in patients with a concussion.

A randomised control trial of walking to ameliorate brain injury fatigue: a NIDRR TBI model system centre-based study.

Fatigue is one of the most commonly reported sequelae after traumatic brain injury (TBI). This study evaluated the impact of a graduated physical activity programme on fatigue after TBI. Using a prospective randomised single-blind crossover design, 123 individuals with TBI, over the age of 18, were enrolled. Interventions included a home-based walking programme utilising a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Nutritional counselling with the same schedule of coaching calls served as the control condition. Main outcome measures included: the Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI) Fatigue Scale Overall Severity Index Score, and the Multidimensional Fatigue Inventory (MFI). Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total, and MFI General scores. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash out period (36 weeks) as measured by the BNI Overall. The study suggests that walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.

Reciprocal Causation Between Functional Independence and Mental Health 1 and 2 Years After Traumatic Brain Injury: A Cross-Lagged Panel Structural Equation Model.

OBJECTIVE: The research attempting to disentangle the directionality of relationships between mental health and functional outcomes after traumatic brain injury (TBI) is growing but has yielded equivocal findings or focused on isolated predictors or isolated outcomes. The purpose of the current study was to use cross-lagged panel and structural equation modeling (SEM) techniques to examine causality between comprehensive indices of mental health (depression, anxiety, and life satisfaction) and functional independence in a national sample of individuals with TBI over the first 2 years after injury. DESIGN: Participants were 4,674 individuals with TBI from the TBI Model Systems Database. RESULTS: The SEM, which yielded good fit indices, suggested that individuals with TBI with greater mental health problems at 1 and 2 years after injury had lower functional independence at those same time points. The standardized path loadings for mental health problems and for functional independence over time were large, suggesting a high degree of consistency in mental health and functional independence across 1 and 2 years. In terms of cross-lag, mental health at Time 1 did not exert a unique effect on functional independence at Time 2, but functional independence at Time 1 exerted a statistically significant but quite small unique effect on mental health at Time 2. CONCLUSIONS: This combination of results suggests that functional independence is only slightly more causal than mental health in the relationship between mental health and functional independence over the first 2 years post-TBI, and that instead, reciprocal causality is a more likely scenario. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) understand the nature of the relationship between mental health problems and functional independence after traumatic brain injury; (2) learn about a novel methodological technique for examining the connections between variables over time; and (3) understand when ongoing support for individuals with traumatic brain injury is necessary. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Factors associated with remission of post-traumatic brain injury fatigue in the years following traumatic brain injury (TBI): a TBI model systems module study.

Post-traumatic brain injury fatigue (PTBIF) is a major problem in the years after traumatic brain injury (TBI), yet little is known about its persistence and resolution. The objective of the study was to identify factors related to PTBIF remission and resolution. TBI Model System registrants at five centres participated in interviews at either one and two years post-injury (Y1-2 Cohort), or two and five years post-injury (Y2-5 Cohort). Characteristics of participants with PTBIF remission were compared to those with PTBIF persistence. Variables studied included the presence of and changes in disability, sleep dysfunction, mood, and community participation. The Functional Independence Measure did not differ significantly between groups or over time. In the Y1-2 Cohort the Fatigue Resolved group scored significantly better on the Disability Rating Scale and Pittsburgh Sleep Quality Index. In the Y2-5 Cohort the Fatigue Resolved group scored significantly higher on a measure of community participation. It was concluded that fewer than half of the sample in each cohort experienced a remission of PTBIF between time points. Persistence of PTBIF 1-2 years post-injury is associated with disability, sleep disturbance, and depression while persistence of fatigue beyond 2 years post-injury appears to be related to participation level, underscoring the potential impact of effective surveillance, assessment, and treatment of this condition in optimising life after TBI. Differences in fatigue progression may point to the presence of different types of PTBIF.

Unintentional injuries after TBI: Potential risk factors, impacts, and prevention.

BACKGROUND: The top three causes of fatal unintentional injuries are falls, motor vehicle crashes, and being struck against or struck by objects or persons. These etiologies also happen to be the leading causes of TBI, a serious public health problem, in the US. Reduced cognitive functioning, poor decision making, increased risk taking, disinhibition, diminished safety skills and substance use, place individuals with TBI at an increased risk for subsequent unintentional injuries. The caregiving, psychological, social and financial burden of initial injuries is enormous. Unintentional injuries post-TBI add to that burden significantly. Many unintentional injuries can be prevented with simple education and environment and lifestyle changes. Injury prevention requires collaboration among many. OBJECTIVE: This literature review will share information regarding potential triggers or causes of unintentional injuries after TBI to identify potential issues. The many impacts of these injuries will be reviewed. Best practices in prevention will be presented. CONCLUSION: Ultimately, education, discussion, and awareness across multiple stakeholders can aid in preventing unintentional injuries after TBI.

Trajectories of Life Satisfaction Over the First 10 Years After Traumatic Brain Injury: Race, Gender, and Functional Ability.

OBJECTIVE: This study investigated the influence of race, gender, functional ability, and an array of preinjury, injury-related, and sociodemographic variables on life satisfaction trajectories over 10 years following moderate to severe traumatic brain injury (TBI). SETTING/PARTICIPANTS: A sample of 3157 individuals with TBI from the TBI Model Systems database was included in this study. DESIGN: Hierarchical linear modeling (HLM) analyses were conducted to examine the trajectories of life satisfaction. MAIN MEASURES: The Functional Independence Measure, Glasgow Coma Scale, and the Satisfaction With Life Scale were utilized. RESULTS: Initial models suggested that life satisfaction trajectories increased over the 10-year period and Asian/Pacific Islander participants experienced an increase in life satisfaction over time. In a comprehensive model, time was no longer a significant predictor of increased life satisfaction. Black race, however, was associated with lower life satisfaction, and significant interactions revealed that black participants' life satisfaction trajectory decreased over time while white participants' trajectory increased over the same time period. Life satisfaction trajectories did not significantly differ by gender, and greater motor and cognitive functioning were associated with increasingly positive life satisfaction trajectories over the 10 years. CONCLUSION: Individuals with more functional impairments are at risk for decreases in life satisfaction over time. Further research is needed to identify the mechanisms and factors that contribute to the lower levels of life satisfaction observed among black individuals post-TBI. This work is needed to determine strategic ways to promote optimal adjustment for these individuals.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURE: Employment. RESULTS: Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury. CONCLUSIONS: These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.