Reporting Guideline for RULER: Rasch Reporting Guideline for Rehabilitation Research: Explanation and Elaboration.

The Rasch Reporting Guideline for Rehabilitation Research (RULER) provides peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply Rasch Measurement (RM) Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform guidance about how to write and evaluate research on rehabilitation outcome assessments. The RULER statement includes an organizing framework and a checklist of 59 recommendations. This companion article supports the RULER statement by providing details about the framework, rationale for the domains and recommendations in the checklist and explaining why these considerations are important for improving consistency and transparency in reporting the results of RM studies. This article is not intended to describe how to conduct RM studies but provides rationale for the essential elements that authors should address in each domain. Consistency and transparency in reporting RM studies will advance rehabilitation research if authors consider these issues when planning their study and include the checklist when they submit their manuscript for peer review. A copy of the checklist can be found at [table 2 in https://doi.org/10.1016/j.apmr.2022.03.013].

Rasch Reporting Guideline for Rehabilitation Research (RULER): the RULER Statement.

The application of Rasch Measurement (RM) Theory to rehabilitation assessments has proliferated in recent years. RM Theory helps design and refine assessments so that items reflect a unidimensional construct in an equal interval metric that distinguishes among persons of different abilities in a manner that is consistent with the underlying trait. Rapid growth of RM in rehabilitation assessment studies has led to inconsistent results reporting. Clear, consistent, transparent reporting of RM Theory results is important for advancing rehabilitation science and practice based on precise measures. Precise measures, in turn, provide researchers, practitioners, patients, and other stakeholders with tools for effective decision making. The goal of this Rasch Reporting Guideline for Rehabilitation Research (RULER: Rasch Reporting Guideline for Rehabilitation Research) is to provide peer-reviewed, evidence-based, transparent, and consistent recommendations for reporting studies that apply RM Theory in a rehabilitation context. The purpose of the guideline is to ensure that authors, reviewers, and editors have uniform expectations about how to write and evaluate research on rehabilitation outcome assessments. A task force of rehabilitation researchers, clinicians, and editors met regularly between November 2018 and August 2020 to identify the need for the guideline, develop an organizing framework, identify content areas, and develop the recommendations. This RULER: Rasch Reporting Guideline for Rehabilitation Research statement includes the organizing framework and a checklist of 59 recommendations. The guideline is supported by an Explanation and Elaboration article that provides more detail about the framework and recommendations in the checklist. A glossary of key terms and a recommended iterations table are provided in supplemental online only materials.

Initial development of a measure of evidence-informed professional thinking.

BACKGROUND AND AIMS: A number of theories have been proposed on clinical expertise and its development in occupational therapy and allied health professions. Clinical reasoning, outcome measurement and evidence-based practice are names for leading conceptualisations. The aim of this research was to develop an operational measure of habits of mind and practice that constitute these desirable professional activities amongst professional therapists. METHODS: Items were developed on the basis of literature review and feedback from an expert panel. An online self-report survey was completed by 107 occupational therapists and other allied health clinicians. Rasch analysis was used to identify and calibrate items that fit the criteria for equal-interval measurement. Residuals from identified equal-interval dimensions were examined using principal components analysis to identify multidimensionality. RESULTS: A two-dimension solution employing 32 items was identified. The first dimension comprised items on Critical Clinical Reasoning and had an item separation of 8.49 (0.99 reliability) and a person separation of 2.93 (0.90 reliability). The second dimension comprised items on Evidence-Informed Practice behaviours and had an item separation of 6.19 (0.97 reliability) and a person separation of 2.97 (0.90 reliability). These dimensions were positively correlated (r = .778, p < .001). We named the overall scale 'Evidence-Informed Professional Thinking', or EIPT. The EIPT measures correlated significantly with 12 of 13 relevant external criterion items. CONCLUSION: Evidence-informed professional thinking can be measured in terms of two correlated probabilistically equal-interval dimensions: Critical Clinical Reasoning and Evidence-Informed Practice behaviours. The EIPT measure should be useful in research on development and application of clinical expertise, quality and outcomes of care and implementation of improved practices among practicing therapists in clinical treatment settings. Further research is recommended to understand the generalisability, strengths, limitations and correlates of EIPT.

Toward improved evidence standards and methods for rehabilitation: recommendations and challenges.

Interventions and programs for people with disability should be based on the best--the most discriminating and rigorous--methods of systematic review and knowledge translation possible. Extant systems for systematic review and practice recommendations have excellent features but severe difficulties are encountered when attempting to apply them to disability and rehabilitation. This article identifies issues in evidence synthesis and linked practice recommendations and describes both new and long-tested methods to address them. Evidence synthesis in disability and rehabilitation can be improved by: explicating criteria for evaluating nonrandomized evidence, including the regression discontinuity, interrupted time series, and single-subject designs, as well as state-of-the-art methods of analysis of observational studies; greater use of meta-analysis; considering effect size, direction of biases, and dose-response relationships; employing more discriminating methods of evaluating flaws in masking, considering also measurement reliability and objectivity; considering overall biases and conflicts of interest; increased attention to composition of review panels; and greater transparency in reporting of the bases of reviewers' judgments. Review methods need to be developed for assistive technology and for measurement procedures. Application to practice can be improved by attention to treatment alternatives, explicit evaluation of generalizability, synthesizing clinical experience as a source of evidence, and a focus on the best--rather than the ideally most-rigorous--evidence. Study outcomes should be measured and reviewed in terms meaningful to persons served. In sum, methods are available to improve evidence synthesis and the application of resulting knowledge. We recommend that these methods be employed.

Developing and using evidence to improve rehabilitation practice.

The Clinical Practice Committee of the American Congress of Rehabilitation sponsored this supplement to address 2 critical, related issues for the rehabilitation field: how to develop clinical rehabilitation research to generate useful, high-quality evidence and how to use evidence to improve rehabilitation practice. The 2 are linked by the methods of evidence-based practice (EBP) used to evaluate research evidence and make recommendations for practice. Supplement authors tackle challenges, such as identifying treatment effects and how study design decisions can impact the internal and external validity of research findings, in 4 articles that describe: a 3-phase process for the development of rehabilitation treatments; small-N study designs; the design, implementation, and statistical analysis of rehabilitation clinical trials; and observational research designs used to compare the effectiveness of rehabilitation treatments. Two articles present contemporary best methods for developing and evaluating rehabilitation prediction models and outcome measures. The supplement also addresses issues of evaluating research evidence and translating evidence into clinical decisions or recommendations. An overview of tools that EBP adherents have developed to help the clinician find, synthesize, and apply evidence is presented, followed by an article that identifies 8 primary steps in the production of a systematic review. The last article outlines 13 recommendations for improving systematic evidence reviews and applying their resulting knowledge to clinical practice. In addition to recommending best methods, the supplement addresses challenges specific to the behavioral complexity of developing rehabilitation research and applying it in a way that improves the health, function, and quality of life of persons served.

Application of the Multicontextual Approach in Promoting Learning and Transfer of Strategy Use in an Individual with TBI and Executive Dysfunction.

The multicontext approach addresses strategy use and self-monitoring skills within activities and contexts that are systematically varied to facilitate transfer of learning. This article illustrates the application of the multicontext approach by presenting a case study of an adult who is 5 years post-traumatic brain injury with executive dysfunction and limited awareness. A single case study design with repeated pre-post measures was used. Methods to monitor strategy generation and specific awareness within intervention are described. Findings suggest improved functional performance and generalization of use of an external strategy despite absence of changes in general self-awareness of deficits. This case describes the multicontext intervention process and provides clinical suggestions for working with individuals with serious deficits in awareness and executive dysfunction following traumatic brain injury.

A multicontext approach to promoting transfer of strategy use and self regulation after brain injury: An exploratory study.

BACKGROUND/AIM: Persons with brain injury frequently demonstrate decreased ability to monitor and apply strategies learned in treatment to everyday situations. The aim of this study is to refine, explore and provide preliminary testing of the multicontext approach in promoting strategy use across situations and increasing self-regulation, awareness and functional performance. METHODS: This study used a single-subject design with repeated measures pre- and post-intervention, with data analysed descriptively and graphically. Four persons with difficulty following multi-step directions, 3-5 years post-TBI, received a nine session intervention programme. Outcome measures included the Awareness Questionnaire, Self-Regulation Skills Interview, Behavior Rating Inventory of Executive Function, Multiple Errands Test and an Executive Function Performance Test sub-task. The process of change within each treatment session was examined with strategy and awareness ratings. RESULTS: All participants demonstrated positive changes in self-regulatory skills and strategy use that was observed across tasks. As expected, general awareness of deficits remained unchanged. Examination of individual participants revealed important, varying patterns of change in strategy use, learning transfer and self-awareness across intervention. CONCLUSIONS: Results provide preliminary support for the feasibility and efficacy of the multicontext approach in promoting transfer of strategy use to enhance functional performance and selective aspects of awareness. Further investigation, including a larger controlled study, is needed to confirm or limit these observations.

Towards guidelines for evaluation of measures: an introduction with application to spinal cord injury.

BACKGROUND: Both clinical practice and research in spinal cord injury (SCI) continue to struggle with issues of the quality and utility of outcome measures employed. Despite widespread deference to dicta on "reliability and validity," systematic means of grading the level of evidence for measures are lacking. OBJECTIVES: This paper explains the methods and principles for use in systematic reviews of measures in SCI. It explains how extant measurement standards and principles can be elaborated for extant labels on various types of reliability and validity to define a more judicious method of grading level of evidence. We aim to initiate a process of discussion that will lead to improved systematic review of the measurement quality as a basis for long-term improvements in outcomes measures and their application. METHODS: This paper is a conceptual review, based on established measurement standards and principles and the incorporation of recent advances in measurement methodology. The scheme of grading of measurement quality is illustrated by examples of measures of health, function, activity/participation, and quality of life after SCI. RESULTS AND CONCLUSIONS: It is possible to grade the quality of outcome measure in terms of level of evidence, provided the nature of the construct being measured is defined as well as its main use. Definite means of grading the level of evidence for measurement will help to identify priorities for measure development and facilitate more appropriate uses of measures.

The uniform postacute assessment tool: systematically evaluating the quality of measurement evidence.

The U.S. Congress has mandated that the Centers for Medicare & Medicaid Services develop a uniform assessment instrument that characterizes patients' needs for postacute services. What scientific criteria should be used to evaluate the evidence for such a tool? The validity of a measure can be accurately graded only if the constructs measured and their applications are clearly defined. We argue that improving postacute placement is the main purpose of the uniform postacute assessment (recently renamed the Continuity Assessment Record and Evaluation). We argue that placement itself needs to be better defined and measured in terms of transitions in the level and type of treatment and care. Domains that should be measured to provide appropriate rehabilitative placement recommendations include level of skilled medical and nursing care, therapies, routine living support, family support, ability to participate in self-care, and patient preference. Almost no research has been performed to quantify and predict the needed intensity of rehabilitative therapy, a major lacuna in evidence. Criteria and examples are provided for research that will provide minimal, probably adequate, or strong evidence for the validity of systems that recommend care transitions. A long-term program of research and systematic evidence synthesis is needed to support guidelines that improve postacute placement.

Preventive services and health behaviors among people with spinal cord injury.

BACKGROUND/OBJECTIVE: To document receipt of certain understudied preventive services and health behaviors in spinal cord injury (SCI) and to compare them to the general adult population. METHODS: Cross-sectional survey. PARTICIPANTS: One hundred ninety-nine community-living adults with SCI residing in New Jersey. MAIN OUTCOME MEASURES: Receipt of recommended general preventive health services, such as screening for colorectal and prostate cancer and dental examinations, and health-related behaviors, including injury prevention, obesity, and tobacco use, as assessed by survey items in the Behavioral Risk Factors Surveillance System. RESULTS: Deficiencies in provision of needed preventive services were evident but were similar to those noted in the general adult population. Among participants 50 years of age or older, 47% had not had either a stool test for occult blood in the last year or a sigmoidoscopy/colonoscopy in the last 5 years. While 43.9% of participants were overweight or obese and 46.3% of these were trying to lose weight, only 1 3.8% had been counseled to lose weight. Twenty-two percent smoked on at least some days. Safety problems were evident: 15.5% did not use seatbelts consistently; 44% had not discussed a fire escape plan at home; and smoke detectors were often not checked adequately. Twelve and a half percent of participants reported having injuries during the last year, and fully 75% of these were related to SCI. Emergency room use and hospitalization were frequent. Participants had a median of 3 to 5 current doctors. CONCLUSIONS: Persons with SCI need the general screening and safety services recommended for all persons. Enhanced efforts will be needed to meet national goals in Healthy People 2010 in SCI.

Health literacy, morbidity, and quality of life among individuals with spinal cord injury.

OBJECTIVES: Health literacy has been related to indicators of health outcomes in a number of populations, but not in spinal cord injury (SCI). The current study aimed to describe levels of health literacy in SCI and to investigate its possible associations with morbidity, health-related quality of life, functional independence, community participation, and life satisfaction. DESIGN: Cross-sectional survey of 107 community-living people with SCI recruited in a New Jersey outpatient SCI center. Primary measures were the Test of Functional Health Literacy in Adults (TOFHLA), standard questions about morbidity from the Behavioral Risk Factors Surveillance Study, the Craig Handicap Assessment and Reporting Technique (CHART), Short Form-12 (SF-12), and Diener's Satisfaction with Life Scale. RESULTS: Health literacy was marginal or inadequate (TOFHLA = 0-74) in only 14% of the sample. TOFHLA scores correlated significantly with physical health morbidity, even after control for severity of motor paralysis and education. American Spinal Injury Association (ASIA) Motor Scores were correlated with physical morbidity and CHART Physical Independence scores; and education was related to community Mobility, Occupation, and Economic Independence, and Satisfaction with Life scores, independent of other factors. Rasch analysis identified ceiling measurement limitations in the TOFHLA. CONCLUSIONS: Health literacy levels in this sample were higher than those found in other groups. Health literacy was independently related to physical health morbidity, but its associations with other outcomes were limited, entwined with education, and affected by severity of injury. Future research might examine higher-level aspects of health literacy to overcome ceiling measurement problems. Mediators of the association between health literacy and morbidity, such as health self-care behaviors, should also be examined.

Modified constraint-induced therapy after subacute stroke: a preliminary study.

OBJECTIVE: To determine the efficacy of a modified constraint-induced therapy (mCIT) administered to patients with subacute stroke. DESIGN: Prospective, multiple-baseline, before-after, randomized clinical trial. SETTING: Subacute outpatient clinic. SUBJECTS: Fourteen patients with subacute stroke who exhibited learned nonuse and stable motor deficits in their affected upper limbs. INTERVENTION: Four patients participated in half-hour, structured physical and occupational therapy sessions that emphasized affected arm use in valued functional activities, 3 times per week for 10 weeks. Their less affected upper limbs were restrained 5 days per week during 5 hours identified as times of frequent use (mCIT). Five patients received regular therapy (TR) with similar therapeutic contact time to mCIT and 5 patients received no therapy (CON). MAIN OUTCOME MEASURES: The Fugl-Meyer Assessment of Motor Recovery (Fugl), Action Research Arm (ARA) test, and Motor Activity Log (MAL). RESULTS: After intervention, Fugl, ARA, and MAL scores remained virtually the same for TR and CON groups; scores improved by 11.4 and 11.5points, respectively, on the Fugl and ARA for the mCIT group. Amount and quality of arm use, as measured by the MAL, also improvedfor mCIT patients (2.49 and 0.47, respectively). CONCLUSIONS: mCIT may be an efficacious method of improving affected arm function and use in stroke patients exhibiting learned nonuse.

Telerehabilitation, cognition and user-accessibility.

Survivors of traumatic brain injury (TBI) often experience cognitive and physical impairments. The aims of this study were to: 1) build an internet-based, "Virtual Rehabilitation Center" (VRC) that provides rehabilitation, education and support services to individuals with TBI; and 2) to determine the relationships between the nature and severity of the participants' cognitive impairments and their ability to use the VRC. Eight individuals with brain injuries (Age: M=43, SD=15.4; Years of Education: M=13.8, SD=3.15) participated. The Neurobehavioral Cognitive Status Exam (NBCSE) was used to assess intellectual functioning. The VRC modules consisted of reaction time, functional modules, and communication capabilities. All participants learned how to use the VRC. However, those requiring more "trials to acquisition" showed greater cognitive impairment than those requiring fewer trials in: Construction (p=0.02), Reasoning-Similarities (p=0.01) and in calculation and language repetition.(i.e., a non-significant trend). Importantly, all participants learned how to use the system although learning rates varied. Moreover, one case-study demonstrated that learning on the VRC generalized to the community. Overall, impairments on the NBCSE in visual-constructional integration and executive-type functions, as well as language processing appeared to be related to how effectively participants learned how to use the VRC.

The effects of physician empathy on patient satisfaction and compliance.

The present study attempted to develop new scales of patient-perceived, empathy-related constructs and to test a model of the relationships of physician empathy and related constructs to patient satisfaction and compliance. Five hundred fifty outpatients at a large university hospital in Korea were interviewed with the questionnaire. The data were analyzed using structural equation modeling. Patient-perceived physician empathy significantly influenced patient satisfaction and compliance via the mediating factors of information exchange, perceived expertise, inter-personal trust, and partnership. Improving physician empathic communication skills should increase patient satisfaction and compliance. Health providers who wish to improve patient satisfaction and compliance should first identify components of their empathic communication needing improvement and then try to refine their skills to better serve patients.

Perceived quality of care and outcomes following spinal cord injury: minority status in the context of multiple predictors.

OBJECTIVE: To determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome. DESIGN: Correlational analysis of longitudinal data. SAMPLE: One hundred and forty-three individuals with SCI in the first year following injury (43.3% tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries). SETTING: Hospital and postdischarge (usually outpatient) care at 3 SCI model systems. MAIN OUTCOME MEASURES: Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standard format. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications, Functional Independence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]). RESULTS: Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount of care, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity of injury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing care (P < 0.03, 0.02, and 0.02, respectively). CONCLUSION: A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with current care from pre-existing biases.

Treatment to improve self-awareness in persons with acquired brain injury.

AIM: To examine the effects of an awareness training protocol embedded within the practice of instrumental activities of daily living (IADLs) in participants with acquired brain injury on levels of self-awareness and functional performance. METHODS: This study used a randomized control trial design: 10 participants with moderate-to-severe brain injury received six sessions of the self-awareness training while they performed IADLs (experimental group) and 10 participants performed the same IADLs but received conventional therapeutic practice (control group). In the experimental group, participants were asked to predict their performance before each task performance and to estimate their performance level after the performance. OUTCOME MEASURES: Pre- and post-intervention outcome measures taken from the two groups were compared. Instruments were standardized measures of 'general' self-awareness with collateral reports by informants (e.g. Awareness Questionnaire); 'task-specific' self-awareness (e.g. Assessment of Awareness of Disability) and Self-Regulation Skills Inventory (SRSI). Performance on IADLs was assessed using the Assessment of Motor and Process Skills (AMPS). RESULTS: Compared to the control group, the intervention significantly improved IADL performances and self-regulation. No significant treatment effect was observed for task-specific self-awareness, general self-awareness or community integration. CONCLUSIONS: The self-awareness intervention significantly but selectively improved self-awareness during IADL task performance as well as functional performance. The need for a larger study with more treatment sessions is discussed.

Applying evidence standards to rehabilitation research.

OBJECTIVE: To describe evidence grading methods employed in the systematic reviews in this special series of articles. To provide an overview of results of these reviews to critique the quality of rehabilitation research. To identify issues in the application of evidence grading methods to rehabilitation. DESIGN: Conceptual review of evidence-based practice and evidence grading methods. English-language research studies on rehabilitation of persons with spinal cord injury, traumatic brain injury, and burn for the 5-yr period of 1999-2004 were reviewed using methods of the American Academy of Neurology supplemented by Cochrane criteria and summarized. RESULTS: Rehabilitation has a shortage of high-level studies. The number of level 1 treatment studies was quite limited (five in spinal cord injury, 15 in traumatic brain injury, 12 in burn rehabilitation), as was the number of level 2 studies (26, 4, and 2, respectively). Despite the large number of correlational studies published, the number of high-level (1 or 2) diagnostic and prognostic studies was surprisingly limited (34, 11, and 5, respectively). The rate of production of high-level studies is rapidly increasing. Problems were encountered in applying standard evidence criteria to complex issues encountered in some studies, suggesting limitations and issues in evidence grading methodology. CONCLUSIONS: Rehabilitation needs more high-level studies. Some improvements in research methodology are relatively affordable (e.g., improved blinding), whereas others are expensive (e.g., large randomized controlled trials). Lower-level investigations reporting promising results need to be followed by more definitive, higher-level trials.

Personal and treatment factors associated with foot self-care among veterans with diabetes.

We developed and validated a survey of foot self-care education and behaviors in 772 diabetic patients with high-risk feet at eight Department of Veterans Affairs medical centers. Principal components analysis identified six subscales with satisfactory internal consistency: basic foot-care education, extended foot-care education, basic professional foot care, extended professional foot care, basic foot self-care, and extended foot self-care (alpha = 0.77-0.91). Despite high illness burden, adherence to foot self-care recommendations was less than optimal; only 32.2% of participants reported looking at the bottom of their feet daily. Independent predictors of greater adherence to basic foot self-care practices included African-American or Hispanic background, perceived neuropathy, foot ulcers in the last year, prior amputation (beta = 0.08- 0.12, p < 0.04-0.001), and provision of greater basic and extended education (beta = 0.16, p < 0.004, and beta = 0.15, p < 0.007). The survey subscales can now be used for evaluating foot care and education needs for persons with high-risk feet.

A natural setting behavior management program for persons with acquired brain injury: a randomized controlled trial.

OBJECTIVE: To investigate the efficacy of a behavior management program delivered in the natural community setting for persons with brain injury and their caregivers. DESIGN: Three-group randomized controlled trial. SETTING: Homes and other community settings. PARTICIPANTS: Thirty-seven persons with traumatic and other acquired brain injury and their caregivers. INTERVENTIONS: Natural Setting Behavior Management (NSBM) involving education and individualized behavior modification program versus education only versus control group. MAIN OUTCOME MEASURES: Changes in frequency of targeted problematic behaviors. Subscale in Questionnaire on Resources and Stress, Maslach Burnout Inventory, and the Neurobehavioral Functioning Inventory. RESULTS: While no significant effects were detected at termination of education only (P<.075) or of NSBM (P<.56), significant treatment effects were found at the main outcome point 3 months after termination of services (P<.002). Rates of disruptive or aggressive behaviors declined significantly in the NSBM group. Differences in caregiver-rated stress, burden, and aggression were not statistically significant. CONCLUSIONS: A program of caregiver education and individualized behavior management in natural settings can decrease the frequency of disruptive behavioral challenges. Larger studies are needed to clarify the duration and intensity of education and individualized treatment required to diminish behavioral challenges and to understand relationships with general stress and burden experienced by caregivers.

The structure of functional and community outcomes following traumatic brain injury.

OBJECTIVES: To investigate the dimensionality of functional and community outcomes following serious TBI. To identify items that fit, misfit or are redundant, as well as to assess person misfit. METHODS: Rating-scale (Rasch) analysis was applied to 1-year follow-up data from 231 cases in the US National TBI Model Systems database. Items selected for analysis included all items indicative of global outcomes, disability, activity or participation. RESULTS: A powerful singular measurement dimension was identified. Item reliability was very high (0.98), as was person reliability (0.97). The dimension fit over 90% of cases; that is approximately 10% of cases displayed anomalous patterns of functioning that indicated that their functioning was not measurable in terms of the general dimension identified. There was tension within the dimension between ratings of dependency (FIM) and cognitive functioning in everyday life (NFI). Most-but not all-neuropsychological test scores misfit the outcome dimension. CONCLUSIONS: Actual dimensionality was distinct from the named scales employed. A unidimensional measure model fit the data much better than expected. This outcome dimension might be called 'general community functioning'. In the future, it should be possible to develop more valid and parsimonious measures of community outcomes following TBI.