Age Suppresses the Association Between Traumatic Brain Injury Severity and Functional Outcomes: A Study Using the NIDILRR TBIMS Dataset.

OBJECTIVES: Recovery from traumatic brain injury (TBI) is extremely difficult to predict, with TBI severity usually demonstrating weak predictive validity for functional or other outcomes. A possible explanation may lie in the statistical phenomenon called suppression, according to which a third variable masks the true association between predictor and outcome, making it appear weaker than it actually is. Age at injury is a strong candidate as a suppressor because of its well-established main and moderating effects on TBI outcomes. We tested age at injury as a possible suppressor in the predictive chain of effects between TBI severity and functional disability, up to 10 years post-TBI. SETTING: Follow-up interviews were conducted during telephone interviews. PARTICIPANTS: We used data from the 2020 NDILRR Model Systems National Dataset for 4 successive follow-up interviews: year 1 (n = 10,734), year 2 (n = 9174), year 5 (n = 6,201), and year 10 (n = 3027). DESIGN: Successive cross-sectional multiple regression analyses. MAIN MEASURES: Injury severity was operationalized using a categorical variable representing duration of posttrauma amnesia. The Glasgow Outcomes Scale-Extended (GOS-E) operationally defined functioning. Sociodemographic characteristics having significant bivariate correlations with GOS-E were included. RESULTS: Entry of age at injury into the regression models significantly increases the association between TBI severity and functioning up to 10 years post-TBI. CONCLUSIONS: Age at injury is a suppressor variable, masking the true effect of injury severity on functional outcomes. Identifying the mediators of this suppression effect is an important direction for TBI rehabilitation research.

Age Moderates the Effect of Injury Severity on Functional Trajectories in Traumatic Brain Injury: A Study Using the NIDILRR Traumatic Brain Injury Model Systems National Dataset.

Age is a risk factor for a host of poor outcomes following traumatic brain injury (TBI), with some evidence suggesting that age is also a source of excess disability. We tested the extent to which age moderates the effect of injury severity on functional trajectories over 15 years post injury. Data from 11,442 participants from the 2020 National Institute of Disability and Independent Living Rehabiitation Research (NIDILRR) Traumatic Brain Injury Model Systems (TBIMS) National Dataset were analyzed using linear mixed effects models. Injury severity was operationally defined using a composite of Glasgow Coma Scale scores, structural imaging findings, and the number of days with post-trauma amnesia. Functioning was measured using the Glasgow Outcomes Scale-Extended. Age at injury was the hypothesized moderator. Race, ethnicity, sex, education, and marital status served as covariates. The results showed a significant confounder-adjusted effect of injury severity and age of injury on the linear slope in functioning. The age effect was strongest for those with mild TBI. Thus, the effects of injury severity on functional trajectory were found to be moderated by age. To optimize outcomes, TBI rehabilitation should be developed specifically for older patients. Age should also be a major focus in TBI research.

Biomarkers in the Degenerative Human Intervertebral Disc Tissue and Blood.

ABSTRACT: Patients with back pain comprise a large proportion of the outpatient practice among physiatrists. Diagnostic tools are limited to clinical history, physical examinations, and imaging. Nonsurgical treatments are largely empirical, encompassing medications, physical therapy, manual treatments, and interventional spinal procedures. A body of literature is emerging confirming elevated levels of biomarkers including inflammatory cytokines in patients with back pain and/or radiculopathy, largely because the protein assay sensitivity has increased. These biomarkers may serve as tools to assist diagnosis and assess outcomes.The presence of inflammatory mediators in the intervertebral disc tissues and blood helped to confirm the inflammatory underpinnings of back pain related to intervertebral disc degeneration. Literature reviewed here suggests that biomarkers could assist clinical diagnosis and monitor physiological outcomes during and after treatments for spine-related pain. Biomarkers must be measured in a large and diverse asymptomatic population, in the context of age and comorbidities to prevent false-positive tests. These levels can then be rationally compared with those in patients with back disorders including discogenic back pain, radiculopathy, and spinal stenosis. While studies reviewed here used "candidate marker" approaches, future nonbiased approaches in clearly defined patient populations could uncover novel biomarkers in clinical management of patients.

The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury.

BACKGROUND: Many United States veterans and active military with a history of traumatic brain injury (TBI) also experience challenges from comorbid posttraumatic stress disorder (PTSD), yet the additional burden of PTSD is not clear. PURPOSE: To address this knowledge gap, this study examined the relationship of PTSD to cognitive, social, and physical functioning and depressive symptoms in veterans recently diagnosed with TBI. METHODS: Veterans were recruited from a VA rehabilitation clinic. The Patient Competency Rating Scale and Center for Epidemiologic Studies Depression Scale measured functioning and depression, respectively. Chart review captured PTSD diagnosis. FINDINGS: In the sample of 83 veterans, 65% had a current PTSD diagnosis. After controlling for sociodemographic variables and TBI severity, PTSD was a significant predictor of lower cognitive, social, and physical functioning and higher depressive symptomatology. DISCUSSION: Clinicians should incorporate PTSD assessment in their work with veterans with TBI. Integrated behavioral health and rehabilitation interventions that provide strategies for veterans to manage TBI symptoms and PTSD are critical.

Geriatric Rehabilitation: Gait in the Elderly, Fall Prevention and Parkinson Disease.

Aging-associated anatomic and physiologic decline begins during the fourth decade of life and progresses over the ensuing decades sometimes to a state of frailty, with the decline amplified when there is deconditioning. Aging-related gait and balance disorders leading to an increased risk of falling can be compensated for with the use of exercise interventions, durable medical equipment, and environmental modifications. Caregiver training is an essential component of geriatric rehabilitation.

Racial/ethnic disparities in disability outcomes among post-acute home care patients.

OBJECTIVE: To examine activities of daily living (ADL) disability outcomes among racially/ethnically diverse elders receiving home care (HC) after hospitalization. METHOD: We conducted a retrospective cohort analysis of single-agency, 2013-2014 Outcome and Assessment Information Set data from older adults who received post-hospitalization HC ( n = 20,674). We measured overall change in ADL disability by summing the difference of standardized admission and discharge scores from nine individual ADL. Associations between race/ethnicity and overall ADL change scores were modeled using general linear regression, adjusting for covariates consistent with the Disablement Model. RESULTS: Overall, patients experienced improvement in ADL disability from HC admission to discharge. However, Asian, African American, and Hispanic patients experienced significantly less improvement compared with non-Hispanic Whites (all p < .001), even after controlling for covariates. DISCUSSION: Racial/ethnic disparities exist in ADL disability improvement among HC patients. Research is needed to clarify mechanisms underlying these disparities. Disablement Model factors may be targets for clinical intervention.

Driving-Related Coping Thoughts in Post-9/11 Combat Veterans With and Without Comorbid PTSD and TBI.

Veterans with a history of PTSD, TBI, and combat driving may experience driving anxiety on their return home and may benefit from using targeted coping strategies.

Combat-related Mild Traumatic Brain Injury: Association between Baseline Diffusion-Tensor Imaging Findings and Long-term Outcomes.

Purpose To determine whether functional outcomes of veterans who sustained combat-related mild traumatic brain injury (TBI) are associated with scalar metrics derived from diffusion-tensor (DT) imaging at their initial postdeployment evaluation. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. From 2010 to 2013, initial postdeployment evaluation, including clinical assessment and brain magnetic resonance (MR) examination with DT imaging, was performed in combat veterans who sustained mild TBI while deployed. Outcomes from chart review encompassed initial postdeployment clinical assessment as well as later functional status, including evaluation of occupational status and health care utilization. Scalar diffusion metrics from the initial postdeployment evaluation were compared with outcomes by using multivariate analysis. Veterans who did and did not return to work were also compared for differences in clinical variables by using t and χ(2) tests. Results Postdeployment evaluation was performed a mean of 3.8 years after injury (range, 0.5-9 years; standard deviation, 2.5 years). After a mean follow-up of 1.4 years (range, 0.5-2.5 years; standard deviation, 0.8 year), 34 of 57 veterans (60%) had returned to work. Return to work was associated with diffusion metrics in multiple regions of white matter, particularly in the left internal capsule and the left frontal lobe (P = .02-.05). Overall, veterans had a mean of 46 health care visits per year during the follow-up period (range, 3-196 visits per year; standard deviation, 41 visits per year). Cumulative health care visits over time were inversely correlated with diffusion anisotropy of the splenium of the corpus callosum and adjacent parietal white matter (P < .05). Clinical measures obtained during initial postdeployment evaluation were not predictive of later functional status (P = .12-.8). Conclusion Differences in white matter microstructure may partially account for the variance in functional outcomes among veterans who sustained combat-related mild TBI. (©) RSNA, 2016.

Preliminary findings of a novel measure of driving behaviors in Veterans with comorbid TBI and PTSD.

Veterans of the military operations in Iraq and Afghanistan are at an elevated risk of driving-related accidents and fatalities compared with civilians. Combat exposure, military driving training, risk-seeking, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) are all factors associated with driving-related risk. However, few empirical studies have observed driving patterns in this population, and the influence of these contributing factors remains unclear. This study utilized a novel self-report measure to assess driving behaviors, subjective driving-related anxiety, and the emotional experiences of military Veterans who have returned to civilian driving. This questionnaire was completed by 23 combat Veterans diagnosed with comorbid TBI and PTSD and 10 nondisabled combat Veterans. Drivers with TBI and PTSD reported more frequent high-risk driving behaviors and higher levels of anxiety while driving in certain situations than nondisabled combat Veterans. These preliminary findings highlight the importance of studying on-the-road situations and cues that produce anxiety in Veterans, particularly those with TBI and PTSD. A greater understanding of driving-related anxiety is needed to inform targeted and effective interventions for unsafe driving in Veterans.

Rating competency in everyday activities in patients with TBI: clinical insights from a close look at patient-family differences.

PURPOSE: Families of patients with traumatic brain injury (TBI) often perceive patients' functional capabilities differently from patients themselves. Research documents inconsistent findings regarding direction of differences. Differences have implications for family support and are germane to clinicians' treatment planning during rehabilitation. We compared two analytic approaches to patient-family differences in ratings of 30 functional tasks: (a) comparing patients' and families' mean scores in domains derived from factor analysis versus (b) examining differences on a task-by-task basis. METHOD: In-home interviews were conducted with 83 outpatients with TBI at a Veteran Affairs polytrauma clinic and for each a family member, using the Patient Competency Rating Scale with both. RESULTS: Principal components analysis identified three functional domains--cognitive, interpersonal/emotional and physical--with significant patient-family differences in the cognitive domain only (family competency ratings were higher). By contrast, task-by-task examination showed significant veteran-family differences in 12 items, mostly in interpersonal/emotional functioning, with mixed directions of differences. The task-by-task approach thus revealed a different picture of patient-family differences than examination by functional domains. CONCLUSIONS: Grouping tasks by domains may obscure important differences in functional ratings. Examination of patient-family differences by task has clinical applications for helping patients and families to manage TBI symptoms and for treatment planning. IMPLICATIONS FOR REHABILITATION: Differences in functional capacity ratings by patients with TBI and their family members are not well understood, with past research demonstrating inconsistencies in direction of difference. Differences in ratings may affect family relationships and may inform clinicians' treatment plans. The study showed that different approaches to analyzing the same data yield two distinct pictures of patient-family differences. Examining patient-family differences by specific tasks is clinically meaningful. The Competency Rating Scale could be used as a clinical tool with patients and families. Its use may improve family understanding of the patient's strengths and struggles and also guide treatment planning.

Cardiovascular effects and enjoyment of exercise gaming in older adults.

The purpose of this study was to quantify the cardiovascular responses and enjoyment of one trial of electronic exercise gaming (EG) (Nintendo(®) Wii(™) Tennis) in healthy, older adults (mean age = 81 [SD = 4 years]). Findings indicate that 15 minutes of EG moderately increased heart rate (p < 0.001), blood pressure (p < 0.001), and perceived exertion (p < 0.0001) compared to resting levels. This corresponded to achieving 64% of age-predicted maximum heart rate. No differences were observed for the cardiovascular responses to EG between genders, but participants taking beta-blocker drugs showed an attenuated response (p < 0.05). All participants completed EG tennis without excessive fatigue, with 86% of participants enjoying the experience. There were only a few cases of EG-related arrhythmias (n = 2) and post-exercise muscle soreness (n = 3). These results suggest that Nintendo Wii Tennis EG technology represents an enjoyable, moderate intensity physical activity for healthy, older adults.

Laser light visual cueing for freezing of gait in Parkinson disease: A pilot study with male participants.

Freezing of gait (FOG) is a debilitating feature of Parkinson disease (PD). In this pilot study, we sought to assess the efficacy of a rolling walker with a laser beam visual cue to treat FOG in PD patients. We recruited 22 subjects with idiopathic PD who experienced on- and off-medication FOG. Subjects performed three walking tasks both with and without the laser beam while on medications. Outcome measures included time to complete tasks, number of steps, and number of FOG episodes. A crossover design allowed within-group comparisons between the two conditions. No significant differences were observed between the two walking conditions across the three tasks. The laser beam, when applied as a visual cue on a rolling walker, did not diminish FOG in this study.

Rehabilitation interventions in Parkinson disease.

OBJECTIVE: This self-directed learning module provides an evidence-based update of exercise-based rehabilitation interventions to treat Parkinson disease (PD). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review emphasizes treatment of locomotion deficits, upper limb motor control deficits, and hypokinetic dysarthria. New dopaminergic agents and deep brain stimulation are facilitating longer periods of functional stability for patients with PD. Adjunctive exercise-based treatments can therefore be applied over longer periods of time to optimize function before inevitable decline from this neurodegenerative disease. As function deteriorates in patients with PD, the role of caregivers becomes more critical, thus training caregivers is of paramount importance to help maintain a safe environment and limit caregiver anxiety and depression. The overall goal of this article is to enhance the learner's existing practice techniques used to treat PD through exercise-based intervention methods.

Falling in Parkinson disease: identifying and prioritizing risk factors in recurrent fallers.

OBJECTIVES: To identify falling risk factors in a study population of recurrent fallers compared with nonfallers who have Parkinson disease, and to prioritize falling risk factors in this patient population to target them for modification. DESIGN: Twenty-three recurrent fallers and 25 nonfallers who have Parkinson disease were recruited, and they participated in a comprehensive assessment probing for the presence of falling risk factors. To identify falling risk factors, a group comparative design was used to compare recurrent fallers and nonfallers across an array of variables. To prioritize those risk factors, modeling using recursive partitioning was performed, entering into the model falling, risk factors identified in this and other studies that were considered potentially modifiable. RESULTS: A specific profile of variables distinguished recurrent fallers who have Parkinson disease in our study population: higher disease severity, higher level of motor impairment, higher level of disability, impaired leg agility or lower-limb coordination, impaired ability to arise from a chair or compromised proximal lower-limb motor control, impaired ambulation, impaired motor planning of the hands and feet, impaired dynamic balance as measured by ability to walk in tandem, and fear of falling. Recursive partitioning prioritized three risk factors: impaired ambulation, impaired lower-limb motor planning, and orthostasis. CONCLUSIONS: In this study, an idiosyncratic falling risk factor profile was demonstrated among our subjects who have Parkinson disease. Three variables were prioritized for potential modification: impaired ambulation, impaired lower-limb motor planning, and orthostasis.

A feasibility study of methodological issues and short-term outcomes in seriously injured older adults.

BACKGROUND: For any given traumatic injury, older adults experience a longer hospitalization, more complications, and higher mortality than do younger patients. OBJECTIVES: To prospectively identify problems in designing follow-up studies in seriously injured older adults without head injury and to examine outcomes after serious trauma in older adults who were sent to a level I trauma center. METHODS: A short-term descriptive follow-up design was used in which each patient served as his or her baseline. Eligible patients had injuries that required admission to an intensive care unit, a hospital length of stay longer than 72 hours, or surgery. Patients with isolated hip fractures, central nervous system injuries, and burn injuries were excluded. Data were collected by using standardized instruments during the acute hospital stay and 3 months after discharge from the hospital. RESULTS: During a representative 2-month period, 21% of a potential 77 subjects died in the hospital, 44% had cognitive impairment that precluded participation, and 17% declined to participate. Twenty older adults (mean age 73.5 years) who were injured in motor vehicle crashes (45%), falls (35%), or pedestrian accidents (15%) or who had gunshot wounds (5%) were enrolled. Ten percent died after discharge. Levels of physical disability at 3 months after discharge were higher than those before the injury (score on Sickness Impact Profile physical subscale 24.5 vs 10.9, P = .02), and psychological distress (Impact of Event Scale score 20.9) remained elevated. CONCLUSION: Mortality, disability, and posttraumatic psychological distress after discharge are problems in seriously injured older adults.