Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review.

OBJECTIVES: To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI). METHODS: A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies. RESULTS: Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported. CONCLUSION: There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

Trends in the Characteristics and Outcomes of Older Medicare Patients With Traumatic Brain Injury Treated in Inpatient Rehabilitation Facilities: 2013 to 2018.

OBJECTIVE: To describe the characteristics and outcomes of older (65+) Medicare beneficiaries with traumatic brain injury (TBI) treated in inpatient rehabilitation facilities between 2013 and 2018. DESIGN: Descriptive study using IRF Patient Assessment Instrument (IRF-PAI) data reporting trends of the sociodemographic and clinical characteristics and outcomes of inpatient rehabilitation facilities Medicare patients with TBI. SETTING: Inpatient rehabilitation facilities in the United States. PARTICIPANTS: 99,804 older Medicare fee-for-service and Medicare Advantage patients with TBI (N=99,804). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay, self-care, and mobility functional outcomes, discharge destination. RESULTS: The number of older Medicare beneficiaries with TBI treated in inpatient rehabilitation facilities increased from 14,657 in 2013 to 18,791 in 2018, an increase of 28.2%. In addition to this overall increase in patients, we also found the percentage of men increased slightly (52.9% to 54.8%), there was a higher percentage of patients with tier 3 comorbidities, there was a decrease in the variability of length of stay, there was slightly more self-care and mobility improvement and a slightly higher percentage of patients discharged to the community (67.8% in 2013 and 71.6% in 2018). Newer standardized data showed that prior to the injury, more than one-third used a walker and more than three-quarters had a history of recent falls. CONCLUSIONS: Between 2013 and 2018, the number of Medicare beneficiaries with TBI treated in IRFs increased by approximately 28%. The characteristics of IRF older patients with TBI changed between 2013 and 2018 toward a slightly higher proportion of men, more comorbidities, and a higher percentage being discharged home after inpatient rehabilitation.

Understanding the Barriers of Implementing a Self-Awareness Assessment in Occupational Therapy Practice within a Brain Injury Population: An Exploratory Study.

Background: Self-awareness is seldom formally assessed by occupational therapists among individuals with traumatic brain injury (TBI). However, impaired self-awareness is prevalent and has a significant impact on rehabilitation outcomes. There is a need to understand clinician perspectives on self-awareness assessments and promote evidence-based practice in clinical settings. Aims: (1) Explore how an education session impacts knowledge and use of self-awareness assessments in occupational therapists working with people with TBI; (2) Understand the barriers that occupational therapists experience when assessing self-awareness in clinical practice. Materials and Methods: A single-group pre-post session design with an integrated knowledge translation approach was used. Occupational therapists working in neurorehabilitation were recruited from two rehabilitation centres through convenience sampling. Participants completed questionnaires before, after, and three months following an education session about the Self-Awareness of Deficits (SADI) assessment. Results: 14 occupational therapists participated in this study. A statistically significant increase in knowledge and confidence in using the SADI was observed both post-session and at 3-month follow-up. Conclusion: Targeted and ongoing education promotes confidence and knowledge retention among occupational therapists. Further research should explore strategies to promote behaviour change. Significance. The barriers identified in this study can provide insights for knowledge translation across clinical contexts.

Effect of Post-traumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA). DESIGN: Multivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data. SETTING: Five VA PRCs. PARTICIPANTS: VA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717). INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Total, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals. RESULTS: A total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse. CONCLUSIONS: This study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.

Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment.

OBJECTIVE: To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI). DESIGN: Retrospective matched cohort study. SETTING: IQVIA Integrated Data Warehouse. PARTICIPANTS: People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis. RESULTS: People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only. CONCLUSIONS: People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.

Exploring employment following traumatic brain injury in persons who completed an insurer funded vocational rehabilitation program in Australia.

PURPOSE: To extend the authors' previous research by investigating the maintenance of work performance over time and the long-term experience of employment following traumatic brain injury (TBI). MATERIALS AND METHODS: Semi-structured interviews were conducted with a sample of 72 individuals with predominantly severe TBI, up to 10-years post-injury. Thematic analysis of transcribed interviews was conducted. RESULTS: Four key themes were identified: brain injury influences on work performance and long-term employment; factors optimising long-term employment; and need for compromise and acceptance, which all impacted the final theme, quality of life outcome. While TBI-related difficulties such as fatigue, cognitive, and emotional difficulties still impacted work many years post-injury, work modifications and employer and vocational rehabilitation (VR) support were important factors optimising long-term employment. The timing of return to work (RTW) was also an important and potentially modifiable factor influencing work performance, which appeared to have long-term effects on the maintenance of employment. Support for acceptance of altered career goals is needed. CONCLUSION: Findings support the need for early VR to facilitate employer contact, to maximise adjustment and preparation time before RTW, to educate both employees and employers and to implement work modifications to support continuing employment after TBI.Implications for rehabilitationThe maintenance of employment following TBI is of critical importance for financial independence, psychological and social well-being, and improved quality of life.Injury-related difficulties still impact work performance many years after injury requiring individuals with TBI to continue working in modified roles and for reduced hours over the long-term.Ongoing VR and employer support is needed to facilitate long-term work modifications and compensatory strategies to support work performance.Early VR involvement to facilitate employer contact and maximise adjustment and preparation time before returning to work is necessary to avoid the negative and potentially dire consequences of returning too early.Psychological support to facilitate acceptance of role changes and career compromises is also important.

Questionnaires vs Interviews for the Assessment of Global Functional Outcomes After Traumatic Brain Injury.

Importance: An interview is considered the gold standard method of assessing global functional outcomes in clinical trials among patients with acute traumatic brain injury (TBI). However, several multicenter clinical trials have used questionnaires completed by a patient or caregiver to assess the primary end point. Objective: To examine agreement between interview and questionnaire formats for assessing TBI outcomes and to consider whether an interview has advantages. Design, Setting, and Participants: This cohort study used data from patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) project from December 2014 to December 2017. Data were analyzed from December 2020 to April 2021. Included patients were aged 16 years or older with TBI and a clinical indication for computed tomography imaging. Outcome assessments were completed using both an interview and a questionnaire at follow-up 3 and 6 months after injury. Exposures: Traumatic brain injury of all severities. Main Outcomes and Measures: Ratings on the Glasgow Outcome Scale-Extended (GOSE) administered as a structured interview rated by an investigator and as a questionnaire completed by patients or caregivers and scored centrally were compared, and the strength of agreement was evaluated using weighted κ statistics. Secondary outcomes included comparison of different sections of the GOSE assessments and the association of GOSE ratings with baseline factors and patient-reported mental health, health-related quality of life, and TBI symptoms. Results: Among the 3691 eligible individuals in the CENTER-TBI study, both GOSE assessment formats (interview and questionnaire) were completed by 994 individuals (26.9%) at 3 months after TBI (654 [65.8%] male; median age, 53 years [IQR, 33-66 years]) and 628 (17.0%) at 6 months (409 [65.1%] male; median age, 51 years [IQR, 31-64 years]). Outcomes of the 2 assessment methods agreed well at both 3 months (weighted κ, 0.77; 95% CI, 0.73-0.80) and 6 months (weighted κ, 0.82; 95% CI, 0.78-0.86). Furthermore, item-level agreement between the 2 methods was good for sections regarding independence in everyday activities (κ, 0.70-0.79 across both time points) and moderate for sections regarding subjective aspects of functioning such as relationships and symptoms (κ, 0.41-0.51 across both time points). Compared with questionnaires, interviews recorded more problems with work (294 [30.5%] vs 233 [24.2%] at 3 months and 161 [26.8%] vs 136 [22.7%] at 6 months), fewer limitations in social and leisure activities (330 [33.8%] vs 431 [44.1%] at 3 months and 179 [29.7%] vs 219 [36.4%] at 6 months), and more symptoms (524 [53.6%] vs 324 [33.1%] at 3 months and 291 [48.4%] vs 179 [29.8%] at 6 months). Interviewers sometimes assigned an overall rating based on judgment rather than interview scoring rules, particularly for patients with potentially unfavorable TBI outcomes. However, for both formats, correlations with baseline factors (ρ, -0.13 to 0.42) and patient-reported outcomes (ρ, 0.29 to 0.65) were similar in strength. Conclusions and Relevance: In this cohort study, GOSE ratings obtained by questionnaire and interview methods were in good agreement. The similarity of associations of the ratings obtained by both GOSE methods with baseline factors and other TBI outcome measures suggests that despite some apparent differences, the core information collected by both interviews and questionnaires was similar. The findings support the use of questionnaires in studies in which this form of contact may offer substantial practical advantages compared with interviews.

Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury.

BACKGROUND/OBJECTIVES: Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments. DESIGN: Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge. SETTING: U.S. skilled nursing facilities (n = 11,771). PARTICIPANTS: Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n = 61,021). MEASUREMENTS: Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility. RESULTS: Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval = 0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge. CONCLUSION: Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.

A 3-Country Assessment of Traumatic Brain Injury Practices and Capacity.

BACKGROUND: The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova. METHODS: After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources. RESULTS: All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries. CONCLUSIONS: Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.

Provider Perspectives on Early Psychosocial Interventions after Pediatric Severe Traumatic Brain Injury: An Implementation Framework.

This study created a framework incorporating provider perspectives of best practices for early psychosocial intervention to improve caregiver experiences and outcomes after severe pediatric traumatic brain injury (TBI). A purposive sample of 23 healthcare providers from the emergency, intensive care, and acute care departments, was selected based on known clinical care of children with severe TBI at a level 1 trauma center and affiliated children's hospital. Semistructured interviews and directed content analysis were used to assess team and caregiver communication processes and topics, prognostication, and recommended interventions. Providers recommended a dual approach of institutional and individual factors contributing to an effective framework for addressing psychosocial needs. Healthcare providers recommended interventions in three domains: (1) presenting coordinated, clear messages to caregivers, (2) reducing logistical and emotional burden of care transitions, and (3) assessing and addressing caregiver needs and concerns. Specific family-centered and trauma-informed interventions included: (1) creating and sharing interdisciplinary plans with caregivers, (2) coordinating prognostication meetings and communications, (3) tracking family education, (4) improving institutional coordination and workflow, (5) training caregivers to support family involvement, (6) performing biopsychosocial assessment, and (7) using systematic prompts for difficult conversations and to address family needs at regular intervals. Healthcare workers from a variety of disciplines want to incorporate certain trauma-informed and family-centered practices at each stage of treatment to improve experiences for caregivers and outcomes for pediatric patients with severe TBI. Future research should test the feasibility and effectiveness of incorporating routine psychosocial interventions for these patients.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Understanding the Multidimensional Nature of Sexuality After Traumatic Brain Injury.

OBJECTIVE: To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI). DESIGN: Survey. Individuals with TBI completed measures at a mean average of 2.78 years post injury (range, 1-10.3y). SETTING: All participants were community based at the time of data collection. PARTICIPANTS: Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex-, and education-matched controls with TBI recruited from the general community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Brain Injury Questionnaire of Sexuality. RESULTS: Individuals with TBI performed significantly worse on sexuality, mood, and self-esteem measures than the control group without TBI, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological, and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression, and lower self-esteem were significant predictors of poorer sexuality post injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI. CONCLUSIONS: These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may affect sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.

Cost-Benefit Analysis From the Payor's Perspective for Screening and Diagnosing Obstructive Sleep Apnea During Inpatient Rehabilitation for Moderate to Severe TBI.

OBJECTIVE: To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective. DESIGN: A cost-benefit analysis of phased approaches to sleep apnea diagnosis. SETTING: Six TBI Model System Inpatient Rehabilitation Centers. PARTICIPANTS: Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). INTERVENTION: Not applicable. MAIN OUTCOME: Cost benefit. RESULTS: At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness. CONCLUSIONS: The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

Supporting caregivers of veterans with Alzheimer's disease and traumatic brain injury: study protocol for a randomized controlled trial.

BACKGROUND: Patients with Alzheimer's disease and related dementias (ADRD) and traumatic brain injury (TBI) and their caregivers require cognitive and behavioral symptom management, interdisciplinary care, support for caregivers, and seamless care coordination between providers. Caring for someone with ADRD or TBI is associated with higher rates of psychological morbidity and burden, social isolation, financial hardship, and deterioration of physical health. Tremendous need exists for primary care-based interventions that concurrently address the care needs of dyads and aim to improve care and outcomes for both individuals with ADRD and TBI and their family caregivers. METHODS: The Aging Brain Care Acquiring New Skills While Enhancing Remaining Strengths (ABC ANSWERS) study is a randomized controlled trial that tests the effectiveness of an intervention based on two evidence-based programs that have been developed for and previously tested in populations with ADRD, TBI, stroke, and late-life depression and/or who have survived an intensive care unit stay. This study includes 200 dyads comprised of a veteran with a diagnosis of ADRD or TBI and the veteran's primary informal caregiver. Dyads are randomized to receive the ABC ANSWERS intervention or routine Veterans Health Administration (VHA) primary care with a standardized educational and resource information packet. Data collection occurs at baseline and three follow-up time points (3 months, 6 months, and 12 months). The primary outcome is caregiver quality of life (QoL). A secondary measure for the caregiver is caregiver burden. Secondary measures for both the veteran and caregiver include symptoms of depression and anxiety. DISCUSSION: The ABC ANSWERS intervention integrates common features of an evidence-based collaborative care model for brain health while concurrently attending to the implementation barriers of delivering care and skills to dyads. We hypothesize that caregivers in dyads randomized to the ABC ANSWERS program will experience higher levels of QoL and lower levels of depression, anxiety, dyadic strain, and caregiver burden at 12 months than those receiving usual VHA primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03397667. Registered on 12 January 2018.

Traumatic brain injury-needs and treatment options in the chronic phase: Study protocol for a randomized controlled community-based intervention.

BACKGROUND: Traumatic brain injury (TBI) is often associated with life-long medical, cognitive, emotional, and behavioral changes. Although long-lasting disabilities are expected, research on effective treatment options in the chronic phase of TBI is scarce. METHODS/DESIGN: This study protocol describes a randomized controlled trial (RCT) aimed at evaluating the effectiveness of a goal-oriented and community-based intervention for increasing community integration, quality of life, and functional independence in the chronic phase of complicated mild to severe TBI. Participants will be recruited from Oslo University Hospital, Norway. Patients aged 18-72 years living at home with MRI/CT-verified intracranial abnormalities, a TBI diagnosis, a time since injury of ≥ 2 years, and who experience either current TBI-related problems or restrictions in community integration will be included. The 120 participants will be randomized 1:1 to either (a) an intervention group, which will receive an in-home intervention program over 4 months, or (b) a control group receiving standard care in the municipalities. The intervention will consist of six home visits and two telephone contacts with a rehabilitation professional. A SMART-goal approach will be adopted to target the individual's self-reported TBI difficulties in everyday life. Primary outcomes will be self-reported quality of life and participation. Secondary outcomes include symptom burden, emotional functioning, and clinician-assessed global outcome and need for rehabilitation services. Outcomes will be evaluated at baseline and 4-5 and 12 months after baseline. Caregiver burden and general health will be assessed in participating family members. Goal attainment and acceptability will be evaluated in the intervention group. A process evaluation will be carried out to evaluate protocol adherence, and a cost-effectiveness analysis will be applied if the intervention is found to be effective. DISCUSSION: The current study provides an innovative approach to rehabilitation in the chronic phase of TBI evaluated using an RCT design that may inform treatment planning, health policies, and coordination of patient care. Further, the study may demonstrate new modes of establishing collaboration and knowledge transition between specialized rehabilitation facilities and local rehabilitation services that may improve patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03545594. Registered on June 4th, 2018.

Structural validity and internal consistency of an ecological observation-based assessment, the Activities of Daily Living Profile.

INTRODUCTION: Direct observation of everyday task performance is considered the most accurate measure of independence for individuals with executive function impairments. However, few observation-based measures have been shown to have sound psychometric qualities and be clinically applicable. The objective of this study was to investigate the Activities of Daily Living (ADL) Profile's structural validity using exploratory factor analyses and internal consistency in order to identify the minimum set of tasks required to achieve reliable scores in each of three ADL environments (personal, home and community). METHODS: Ninety-one persons with a severe traumatic brain injury aged 16-40 years (convenience sample) were recruited from a university affiliated level 1 trauma hospital. The 17 observation-based tasks of the ADL Profile were administered by one of five occupational therapists, either in the hospital or in the subjects' home and community environments. This measure of independence considers goal formulation, planning, carrying out and verifying goal attainment. RESULTS: Exploratory factor analysis indicated the unidimensionality of the 17 tasks of the ADL Profile. A single factor explained more than 80% of the common variation, which in this case is the concept of independence. Internal consistency of task scores is very high (0.955), suggesting redundancy of the tasks. Approaches used to reduce the number of items, and to optimise the clinical applicability of the tool, showed that a minimum of two tasks per each of three environments (personal, home, community) is required to obtain reliable results that respect the tool's internal structure. Each assessment should contain both simple and familiar and more novel and complex tasks. CONCLUSIONS: Findings show that the ADL Profile is a valid and clinically applicable observation-based measure of independence that considers four important task-related components: goal formulation, planning, carrying out and verifying goal attainment.

Functional Outcome Trajectories Following Inpatient Rehabilitation for TBI in the United States: A NIDILRR TBIMS and CDC Interagency Collaboration.

OBJECTIVE: To describe trajectories of functioning up to 5 years after traumatic brain injury (TBI) that required inpatient rehabilitation in the United States using individual growth curve models conditioned on factors associated with variability in functioning and independence over time. DESIGN: Secondary analysis of population-weighted data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: A total of 4624 individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES: Ratings of global disability and supervision needs as reported by participants or proxy during follow-up telephone interviews at 1, 2, and 5 years postinjury. RESULTS: Many TBI survivors experience functional improvement through 1 and 2 years postinjury, followed by a decline in functioning and decreased independence by 5 years. However, there was considerable heterogeneity in outcomes across individuals. Factors such as older age, non-White race, lower preinjury productivity, public payer source, longer length of inpatient rehabilitation stay, and lower discharge functional status were found to negatively impact trajectories of change over time. CONCLUSIONS: These findings can inform the content, timing, and target recipients of interventions designed to maximize functional independence after TBI.

Linking the behavioral assessment screening tool to the international classification of functioning, disability, and health as a novel indicator of content validity.

Purpose: To use the International Classification of Functioning, Disability, and Health (ICF) to classify and describe the concepts of the Behavioral Assessment Screening Tool (BAST), a measure of behavioral disruptions after traumatic brain injury (TBI).Methods: Meaningful concepts in the BAST were linked to the International Classification of Functioning to (1) further explore the validity of the conceptual model of behavior; (2) demonstrate ICF linking as a novel indicator of the content validity; (3) identify International Classification of Functioning concepts that characterize behavior; (4) determine the comprehensiveness of the BAST.Results: The body functions component and the activities and participation component were most frequently addressed in the BAST. The majority of the TBI Core Set categories were included in the BAST and the manifest and latent coders agreed 85% of the time.Conclusions: Linking BAST concepts to the International Classification of Functioning demonstrated the BAST's content validity and comprehensiveness. This approach provides a model for how ICF coding could be used to assess content validity.Implications for RehabilitationICF coding can be used to assess content validity and refine rehabilitation measures.The Behavioral Assessment Screening Tool can be used for clinical and research purposes to assess behavior as it relates to a wide range of ICF TBI Core Set categories.

Incidence of stroke and traumatic brain injury in New Zealand: contrasting the BIONIC and ARCOS-IV studies.

AIMS: Traumatic Brain Injury (TBI) and stroke are the main causes of acquired brain injury. The differences in demographic profiles of stroke and TBI suggest that high-quality epidemiological studies of the two be compared. This study examined incidence of stroke and TBI by age and ethnicity in New Zealand. METHODS: Incidence rates are presented by age and ethnicity from two New Zealand population-based epidemiological studies (Brain Injury Outcomes New Zealand In the Community (BIONIC); and Auckland Regional Outcomes of Stroke Studies (ARCOS-IV)). RESULTS: Males and females had similar stroke risk, while males had 2x relative risk of mild TBI and 3x the relative risk of moderate/severe TBI compared to females. More TBI cases (35.6%) were identified through non-medical sources compared to stroke (3%). Incidence of TBI was greater than 5 times that of stroke. New Zealand European/Pakeha had the highest TBI incidence when less than 5 years of age, while Maori had the highest incidence after five years of age. For stroke, Pacific people and Maori had higher incidences until 75-84 years, after which Europeans had higher incidence. CONCLUSIONS: Differences in TBI and stroke incidence suggest targeting prevention very differently for the two groups. Incidence profiles suggest TBI is much more common; and a need to target males and those of Maori ethnicity for TBI prevention.