Determinants of Discharge Disposition From Acute Care for Survivors of Hypoxic-Ischemic Brain Injury: Results From a Large Population-Based Cohort Data Set.

OBJECTIVE: To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex. DESIGN: Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model. SETTING: Acute care. PARTICIPANTS: Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care. RESULTS: The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence). CONCLUSIONS: Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Menopause, anti-Müllerian hormone and cognition in a cohort of women with persistent symptoms following TBI: a case for future research.

Objectives: Primary: To explore anti-Müllerian Hormone (AMH) levels in community dwelling women following TBI. Secondary: To explore the relation of AMH to menstrual cycle, cognition, distress and symptoms of menopause.Setting: Large adult TBI outpatient clinic in Toronto Canada.Research design: Prospective study of 10 women with persistent symptoms who were one or more years post TBI.Methods: Consenting participants provided a serum sample for AMH levels, and completed the Menopause Rating Scale (MRS), Symptom Checklist-90 r (SCL-90 r), Repeatable Battery for the Assessment of Neurological Status (RBANS) and a health questionnaire.Main outcomes and results: This study found lower than expected levels of AMH in 50% of participants relative to age matched norms and 50% of participants experienced new onset of menstrual changes. Also notable were findings of lower-than-expected cognitive scores in women over 35 and reports of menopause-related symptoms across all ages groups.Conclusions: As our understanding of the role of AMH grows, examining changes in this novel biomarker in the long-term post-TBI is warranted. Future research should be sufficiently powered to expand on and validate the study's findings.

Predictors of in-hospital mortality following hypoxic-ischemic brain injury: a population-based study.

Objective: To identify predictors of in-hospital mortality following Hypoxic-Ischemic Brain Injury (HIBI) using the Anderson Behavioral Model.Design and Setting: Population based retrospective cohort study in Ontario, Canada with data collected between 1 April 2002 and 31 March 2017.Patients: Adult patients aged 20 years and older with HIBI-related acute care admission were identified in the health administrative data. Multivariable cox proportional hazard regression models were used to identify predisposing, need and enabling factors that predict in-hospital mortality.Results: Of the 7492 patients admitted to acute care with HIBI, the in-hospital mortality rate was 71%. The predisposing factors associated with mortality were female sex (HR, 1.16; 95% CI, 1.10-1.23) and older age (65-79 vs. 20-34: HR, 1.17; 95% CI, 1.02-1.35). The need factors associated with mortality were the presence of COPD (HR, 1.10; 95% CI, 1.02-1.17), psychiatric illness (HR, 1.13; 95% CI, 1.05-1.20) injury due to cardiac illness (HR, 1.19; 95% CI, 1.12-1.26) and longer emergency department length of stay. Having spending any time in an alternate level of care and the application of tracheotomy procedures were found to reduce mortality.Conclusions: The acute/critical care centers need to consider these findings to adopt prevention strategies targeting reduced in-hospital mortality.

Change in Function Over Inpatient Rehabilitation After Hypoxic Ischemic Brain Injury: A Population-Wide Cohort Study.

OBJECTIVE: To estimate change in motor, cognitive, and overall functional performance during inpatient rehabilitation (IR) and to identify potential determinants of these outcomes among patients with hypoxic-ischemic brain injury (HIBI). DESIGN: Population-based retrospective cohort study using Ontario's health administrative data. SETTING: Inpatient rehabilitation. PARTICIPANTS: Survivors of HIBI 20 years and older discharged from acute care between fiscal years 2002-2003 and 2010-2011 and admitted to IR within 1 year of acute care discharge (N=159). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Functional status as measured by FIM, total, and scores on motor and cognitive subscales. RESULTS: A higher proportion (77%) of HIBI patients in the study were male and 28% were older than 65 years. We observed material improvements in FIM total, motor, and cognitive scores from across the IR episode. Potential determinants of total FIM gain were living in rural location (ß, 10.4; 95% CI, 0.21-21), having shorter preceding acute care length of stay (15-30 vs >60 days ß, 10.4; 95% CI, 1.4-19.5), and failing to proceed directly to IR following acute care discharge (ß, 8.7; 95% CI, 1.8-15.5). Motor FIM gain had similar identified potential determinants. Identified potential determinants of cognitive FIM gain were shorter (ie, 31-60 vs >60 days) preceding acute care, longer IR and length of stay, and proceeding directly to IR. There were no sex differences in functional gain. CONCLUSIONS: Inpatient rehabilitation is beneficial to HIBI survivors. Timely access to these services may be crucial in achieving optimal outcomes for these patients.

Cognitive and Motor Recovery and Predictors of Long-Term Outcome in Patients With Traumatic Brain Injury.

OBJECTIVES: To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. DESIGN: Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. SETTING: IR in Ontario, Canada. PARTICIPANTS: Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. RESULTS: Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval, .02 to .09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. CONCLUSION: Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

Predictors of Discharge Destination From Acute Care in Patients With Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To systematically review studies on clinical and nonclinical predictors of discharge destination from acute care in patients with traumatic brain injury. METHODS: The search was conducted using 7 databases up to December 2016. A systematic review and in-depth quality synthesis were conducted on eligible articles that met the inclusion criteria. RESULTS: The search yielded 8503 articles of which 18 studies met the inclusion criteria. This study demonstrated that a larger proportion of patients with traumatic brain injury were discharged home. The main predictors of discharge to a setting with rehabilitation services versus home included increasing age, white and non-Hispanic race/ethnicity, having insurance coverage, greater severity of the injury, and longer acute care length of stay. Age was the only consistent factor that was negatively associated with discharge to inpatient rehabilitation facilities versus other institutions. CONCLUSION: Results of this study support healthcare providers in providing consultation to patients about the expected next level of cares while considering barriers that may helpful in effective discharge planning, decreasing length of stay and saving resources. These findings also suggest the need for further studies with a stronger methodology on the contribution of patients and families/caregivers to distinguish the predictors of discharge to dedicated rehabilitation facilities.

Content of inpatient rehabilitation for patients with traumatic brain injury: A comparison of Canadian and American facilities.

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIMTM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p < .001, Cohen's d > .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Research Priorities for Optimizing Long-term Community Integration after Brain Injury.

OBJECTIVE: This paper reports on a funded summit, which convened a multidisciplinary group of experts to provide consensus on the research priorities necessary for improving long-term community integration of individuals with traumatic brain injury (TBI) and their caregivers. METHODS: The 2-day summit was directed using the World Café Methodology, to engage stakeholders and collaboratively arrive at a consensus on the problems to be targeted in research. Participants (n=54), drawn from two Canadian provinces, included an interdisciplinary group of researchers, clinicians, representatives from brain injury associations, individuals with TBI, and caregivers. In small groups, participants discussed challenges to long-term community integration and potential initiatives that would address these barriers. Field notes from the discussions were analyzed using qualitative content analysis. RESULTS: The consensus on prioritized research directions included developing interventions to optimize the functioning and participation of individuals with TBI, reducing caregiver burden, and evaluating how emerging technology can facilitate delivery of care. CONCLUSIONS: The World Café Methodology was an effective method for developing research priorities. The breadth of expertise of participants and the collegial environment allowed for the identification of a broad perspective on important future research directions with potential to enhance the long-term community integration of individuals with brain injury.

Association between cognitive ability and functional outcomes following traumatic brain injury- using a computer-based neurocognitive battery.

OBJECTIVE: To investigate the contribution of the Cogstate Brief Battery (CBB TM) in the explanation of variation of functional outcomes. DESIGN: Secondary analysis of the practice-based evidence data set. SETTING: Inpatient rehabilitation setting. PARTICIPANTS: Patients (≥ 18 years of age) with traumatic brain injury who were consecutively admitted to the Toronto Rehabilitation Institute between 2008 and 2011 (n = 65). INTERVENTIONS: Not applicable Main outcome measure: Cognitive and motor components of the Functional Independence Measure. RESULTS: The addition of the CBB TM components resulted in a significantly better model for predicting outcomes than a basic model using demographics and clinical factors. Among all CBB TM components, speed and variation in the identification task and accuracy in the one card learning task were significantly associated with cognitive functional outcomes after controlling for demographic and clinical factors. Rehabilitation length of stay was the only significant clinical factor that was correlated with both cognitive and motor outcomes. CONCLUSIONS: Findings of this study suggest the importance of considering visual attention and visual memory in predication of cognitive outcome and provide valuable information for researchers to consider the specific cognitive abilities in functional outcome model in future studies in addition to more traditional factors.

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study.

OBJECTIVE: To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode. DESIGN: Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge. SETTING: Inpatient rehabilitation. PARTICIPANTS: We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to IR. RESULTS: Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46-.84). CONCLUSIONS: Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.

Long-Term Health Service Outcomes Among Women With Traumatic Brain Injury.

OBJECTIVES: To (1) assess long-term health care service utilization and satisfaction with health care services among women with traumatic brain injury (W-TBI); (2) examine barriers that prevent W-TBI from receiving care when needed; and (3) understand the perceived supports available for W-TBI. DESIGN: Retrospective cohort study. SETTING: Community. PARTICIPANTS: W-TBI (n=105) 5 to 12 years postinjury and women without TBI (n=105) matched on age, education, and geographic location. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pre- and postinjury data were collected using a questionnaire administered via a semistructured interview. Questions on health services utilization, satisfaction with and quality of services, barriers to receiving care, and perceived social support were from the Canadian Community Health Survey; additional questions on perceived social support were from another large-scale study of people with moderate to severe brain injury. RESULTS: Compared with women without TBI, W-TBI reported using more family physician and community health services. W-TBI reported that they did not receive care when needed (40%), particularly for emotional/mental health problems. Significantly more W-TBI reported financial and structural barriers. There were no significant differences in reported satisfaction with services between women with and without TBI. CONCLUSIONS: Health service providers and policymakers should recognize the long-term health and social needs of W-TBI and address societal factors that result in financial and structural barriers, to ensure access to needed services.

Institutional Variation in Traumatic Brain Injury Acute Rehabilitation Practice.

OBJECTIVE: To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. DESIGN: Secondary analysis of a prospective, multicenter, cohort database. SETTING: TBI inpatient rehabilitation programs. PARTICIPANTS: Patients with complicated mild, moderate, or severe TBI (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. RESULTS: A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. CONCLUSIONS: This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered.

Psychotropic Medication Use During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. DESIGN: Prospective observational cohort. SETTING: Multiple acute inpatient rehabilitation units or hospitals. PARTICIPANTS: Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. CONCLUSIONS: Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.

Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Daytime Agitated Behavior Scale scores. RESULTS: Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. CONCLUSIONS: Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials.

Rehospitalization During 9 Months After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Multicenter observational cohort. SETTING: Community. PARTICIPANTS: Individuals with TBI (N=1850) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. RESULTS: A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non-brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk. CONCLUSIONS: Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols.

Mindfulness-based cognitive therapy reduces symptoms of depression in people with a traumatic brain injury: results from a randomized controlled trial.

OBJECTIVE: We sought to determine if we could reduce symptoms of depression in individuals with a traumatic brain injury using mindfulness-based cognitive therapy. SETTING: The study was conducted in a community setting. PARTICIPANTS: We enrolled adults with symptoms of depression after a traumatic brain injury. DESIGN: We conducted a randomized controlled trial; participants were randomized to the 10-week mindfulness-based cognitive therapy intervention arm or to the wait-list control arm. MAIN MEASURES: The primary outcome measure was symptoms of depression using the Beck Depression Inventory-II. RESULTS: The parallel group analysis revealed a greater reduction in Beck Depression Inventory-II scores for the intervention group (6.63, n = 38,) than the control group (2.13, n = 38, P = .029). A medium effect size was observed (Cohen d = 0.56). The improvement in Beck Depression Inventory-II scores was maintained at the 3-month follow-up. CONCLUSION: These results are consistent with those of other researchers that use mindfulness-based cognitive therapy to reduce symptoms of depression and suggest that further work to replicate these findings and improve upon the efficacy of the intervention is warranted.

Early neuropsychological tests as correlates of return to driving after traumatic brain injury.

OBJECTIVE: To assess the ability of neuropsychometric tests administered during inpatient rehabilitation to predict return to driving after traumatic brain injury (TBI). DESIGN: Retrospective, matched case-controlled study. METHODS: Sixty-seven participants with TBI, drawn from an existing database, completed a questionnaire that assessed return to driving post-TBI, as measured by reinstatement of the driver's license. Drivers were individually case-matched to non-drivers on age, Glasgow Coma Scale (GCS), Disability Rating Scale (DRS) and the rehabilitation admission interval (RAI). Scores on four neuropsychological tests (Trail-Making A, Trail Making B, Digit Span-forward and Digit Span-backward), administered during the rehabilitation stay, were compared between case-matched drivers and non-drivers. OUTCOME MEASURE: Return to driving, as defined by reinstatement of the driver's license. RESULTS: Participants who had returned to driving were comparable to those who had not returned to driving with respect to demographic variables, initial injury severity and baseline functioning. Scores on two neuropsychological assessments were significantly better in participants who had returned to driving than in those who had not: Trail-making A (p < 0.01) and Trail-making B (p < 0.01). CONCLUSIONS: The results suggest that neuropsychological measures of processing speed and cognitive flexibility may predict return to driving after TBI.

Functional independence measure at rehabilitation admission as a predictor of return to driving after traumatic brain injury.

OBJECTIVE: To examine the utility of three common measures as predictors of return to driving after traumatic brain injury (TBI): Glasgow Coma Score (GCS) within the first 24 hours of injury and both Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation admission. METHODS: Seventy-two participants with TBI completed a questionnaire that assessed return to driving post-TBI, as measured by reinstatement of the driver's license. Participants who did not return to driving for non-medical reasons or who had not driven pre-injury and did not obtain a driver's license post-injury were excluded from analysis. This produced a final sample of 59 participants. Scores on GCS, FIM and DRS, leveraged from an existing database, were compared between participants who had and those who had not returned to driving post-injury. Multiple logistic regression analysis was performed to determine the relationship of each predictor variable to return to driving. RESULTS: Only the FIM score at rehabilitation admission was significantly associated with return to driving (p < 0.01). FIM score had a sensitivity of 72% and specificity of 73% with respect to return to driving. CONCLUSIONS: This study supports the use of FIM at rehabilitation admission as a predictor of return to driving. Future studies should be directed at identifying other measures to be used in combination with FIM to accurately predict return to driving post-TBI.

Efficacy of a functionally-based neurorehabilitation programme: a retrospective case-matched study of rehabilitation outcomes following traumatic brain injury.

OBJECTIVE: To investigate the efficacy of a functionally-based neurorehabilitation programme. DESIGN: Retrospective, case-matched cohort design. SETTING: An inpatient acquired brain injury (ABI) service at a post-acute rehabilitation facility. In 2001, a functionally-based rehabilitation model was introduced that streams patients into neurocognitive (NC) and neurophysical (NP) treatment groups based on predominant functional deficits. METHODS: Sixty-nine patients with TBI admitted to the ABI service before implementation of the functionally-based programme comprised a historical control group. These patients were individually case-matched to 69 participants admitted after the functionally-based programme began. Rehabilitation outcomes were compared between matched patients treated before and after implementation of the programme. OUTCOME MEASURES: Rehabilitation length of stay (RLOS), Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and FIM efficiency. RESULTS: At discharge, the NP-stream had a significantly higher FIM motor efficiency compared to the historical control (0.41 vs. 0.29; p = 0.01). The NC-stream had significantly less disability, as measured by the DRS, compared to its control (3.63 vs. 5.05; p = 0.01). CONCLUSIONS: This study presents preliminary evidence that a rehabilitation programme that targets functional needs rather than diagnosis may be useful in improving function after traumatic brain injury.

Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI.

OBJECTIVE: To longitudinally examine objective and self-reported outcomes for recovery of cognition, communication, mood and participation in adults with traumatic brain injury (TBI) and co-morbid post-traumatic sleep/wake disorders. DESIGN: Prospective, longitudinal, single blind outcome study. SETTING: Community-based. PARTICIPANTS: Ten adults with moderate-severe TBI and two adults with mild TBI and persistent symptoms aged 18-58 years. Six males and six females, who were 1-22 years post-injury and presented with self-reported sleep/wake disturbances with onset post-injury. INTERVENTIONS: Individualized treatments for sleep/wake disorders that included sleep hygiene recommendations, pharmacological interventions and/or treatments for sleep apnea with follow-up. MAIN OUTCOME MEASURES: Insomnia Severity Index, Beck Depression and Anxiety Inventories, Latrobe Communication Questionnaire, Speed and Capacity of Language Processing, Test of Everyday Attention, Repeatable Battery for the Assessment of Neuropsychological Status, Daily Cognitive-Communication and Sleep Profile. RESULTS: Group analysis revealed positive trends in change for each measure and across sub-tests of all measures. Statistically significant changes were noted in insomnia severity, p = 0.0003; depression severity, p = 0.03; language, p = 0.01; speed of language processing, p = 0.007. CONCLUSIONS: These results add to a small but growing body of evidence that sleep/wake disorders associated with TBI exacerbate trauma-related cognitive, communication and mood impairments. Treatment for sleep/wake disorders may optimize recovery and outcomes.