Perceived care partner burden at 1-year post-injury and associations with emotional awareness, functioning, and empathy after TBI: A TBI model systems study.

BACKGROUND: People with traumatic brain injury (TBI) can lack awareness of their own emotions and often have problems with emotion dysregulation, affective disorders, and empathy deficits. These impairments are known to impact psychosocial behaviors and may contribute to the burden experienced by care partners of individuals with TBI. OBJECTIVE: To examine the associations of emotional awareness, emotional functioning, and empathy among participants with TBI with care partner burden. METHOD: This multisite, cross-sectional, observational study used data from 90 dyads (participants with TBI and their care partner) 1-year post-injury. Participants with TBI completed the Difficulty with Emotional Regulation Scale (DERS; Awareness, Clarity, Goals, Impulse, Nonacceptance, and Strategies subscales); PTSD Checklist-Civilian Version; NIH Toolbox Anger-Affect, Hostility and Aggression Subdomains; PHQ-9; GAD-7; and the Interpersonal Reactivity Index (empathic concern and perspective taking subscales). Care partners completed the Zarit Burden Inventory (ZBI) and provided demographic information. RESULTS: Care partners were predominately female (77%), and most were either a spouse/partner (55.2%) or parent (34.4%). In an unadjusted model that included assessments of emotional awareness, emotional functioning, and empathy of the participant with TBI, the DERS-Awareness and NIH-Hostility subscales accounted for a significant amount of variance associated with care partner burden. These findings persisted after adjusting for care partner age, relationship, education, and the functional status of the participant with TBI (ß= 0.493 and ß= 0.328, respectively). CONCLUSION: These findings suggest that high levels of hostility and low emotional self-awareness can significantly affect the burden felt by TBI care partners.

Linguistic and Cultural Acceptability of a Spanish Translation of the Ohio State University Traumatic Brain Injury Identification Method Among Community-Dwelling Spanish-Dominant Older Adults.

OBJECTIVE: Our objective was to (1) evaluate the linguistic and cultural acceptability of a Spanish translation of the Ohio State University traumatic brain injury identification method (OSU TBI-ID) and (2) to assess the usability and acceptability of a tablet-based version of this instrument in a cohort of Spanish-dominant older adults. SETTING: University clinical research center and local community center. PARTICIPANTS: Community-dwelling Spanish-dominant adults age 50 years or older without dementia residing in the Bay Area of California (N=22). DESIGN: Cross-sectional cohort study. MAIN OUTCOME MEASURES: Qualitative assessment of linguistic or cultural acceptability of a Spanish translation of the OSU TBI-ID as well as usability or acceptability of a tablet-based self-administered version of this instrument. RESULTS: The Spanish translation had high linguistic and cultural acceptability and was further optimized based on participant feedback. Cognitive interviews to review survey wording revealed high levels of homogeneity in the clinical definitions and synonyms given by participants-for example, results for the clinical term "Quedó Inconsciente/Pérdida (temporal) de la conciencia" (To be unconscious/[Temporary] loss of consciousness) used in the survey included "perder el conocimiento" (loss of consciousness), "knockeado" (knocked out), "No es que esté dormida, porque está inconsciente, pero su corazón está todavía palpitando" (it's not that they're sleeping, because they're unconscious, but their heart is still palpitating). The tablet interface had low observer-based usability, revealing that participants with <13 years of education (n=6) had more difficulty using the tablet which could be improved with minor changes to the coding of the application and minimal in-person technology support. Acceptability of the tool was low among all but 1 participant. CONCLUSION: This linguistically optimized Spanish translation of the OSU TBI-ID is recommended for use as a semistructured interview among Spanish-dominant older adults. Although the tablet-based instrument may be used by interviewers as an efficient electronic case report form among older adults, further research is needed, particularly among older adults with varying levels of education, to validate this instrument as a self-administered survey.

The Association of Rehospitalization With Participation 5 Years After Traumatic Brain Injury.

OBJECTIVE: To determine whether rehospitalization during the first 2 years after moderate to severe traumatic brain injury (TBI) is associated with poor participation at 5 years post-TBI, after controlling for demographic and severity factors. SETTING: TBI Model Systems Program. PARTICIPANTS: Community-dwelling individuals with TBI, 16 years or older (n = 1940). DESIGN: Retrospective data analysis of a multicenter prospective study. MAIN MEASURES: Participation Assessment with Recombined Tools-Objective (PART-O). RESULTS: After controlling for demographic and severity factors, a general linear model indicated that rehospitalization status (ie, never rehospitalized during years 1 and 2, rehospitalized either during year 1 or 2, or rehospitalized during both years 1 and 2) predicted less participation at 5 years post-TBI (P = .0353). The PART-O scores were in the hypothesized direction, with the lowest covariate-adjusted mean participation score found for the group with rehospitalizations during both years and the highest covariate-adjusted mean participation score found in the group with no rehospitalizations. Examining total number of rehospitalizations during years 1 and 2, rather than rehospitalization status, yielded analogous results (P = .0148). CONCLUSIONS: This study suggests that rehospitalization in the first 2 years after TBI is negatively associated with participation at 5 years after injury. Since participation is considered a key indicator of successful TBI rehabilitation, minimizing the need for rehospitalizations and promoting health in the community setting should be a priority of postacute care for individuals with TBI.

Examining Driving and Participation 5 Years After Traumatic Brain Injury.

Participation is often considered a primary goal of traumatic brain injury (TBI) rehabilitation, but little is known about the influence of driving on participation after TBI. The objective of this study was to examine the independent contribution of driving status to participation at 5 years post TBI, after controlling for demographic, psychosocial, and functional factors. Participants ( N = 2,456) were community-dwelling individuals with moderate to severe TBI, age 18 to 65 at time of injury, and enrolled in the TBI Model Systems (TBIMS) National Database (NDB). Hierarchical linear regressions for the dependent variable of participation at 5 years post TBI were performed. Findings showed that driving was a highly significant independent predictor of participation and was a stronger relative predictor of participation than FIM® Cognitive, FIM® Motor, and depression. The independent contribution of driving to participation suggests the need to develop evidenced-based occupational therapy assessments and interventions that facilitate safe engagement in the occupation of driving to address the long-term goal of improved participation.

Predicting the Trajectory of Participation After Traumatic Brain Injury: A Longitudinal Analysis.

OBJECTIVE: To identify factors that predict trajectories of participation over the first 5 years after moderate to severe traumatic brain injury (TBI). SETTING: TBI Model System Programs. PARTICIPANTS: Community-dwelling individuals with TBI, 16 years of age or older (n = 1947). DESIGN: Secondary analysis of a prospective, nonrandomly sampled, longitudinal data registry. MAIN MEASURES: Participation Assessment with Recombined Tools-Objective (PART-O). RESULTS: Age at injury and FIM Motor score predicted trajectory of participation over the first 5 years after moderate to severe TBI. Older age predicted generally worse participation overall as well as progressively worsening participation over time. Higher FIM Motor raised the predicted participation values, although it reduced the rate of improvement in participation scores over time. FIM Cognitive scores, race, depression, years of education, and living setting did not predict trajectory but did significantly influence participation consistently at all time points. CONCLUSION: The trajectories of participation over the first 5 years after TBI can be predicted by age at injury and FIM Motor scores. These findings may enhance the ability of rehabilitation professionals to identify individuals at risk for poor participation after TBI and develop targeted interventions for optimizing involvement in life activities.

Lifetime History of Traumatic Brain Injury and Current Disability Among Ohio Adults.

OBJECTIVE: To examine the associations between lifetime history of traumatic brain injury (TBI) with loss of consciousness (LOC) and several types of current disability among adult, noninstitutionalized residents of Ohio. PARTICIPANTS: 2014 Ohio Behavioral Risk Factors Surveillance System participants (n = 6998). DESIGN: Statewide population-based survey. MAIN MEASURES: Lifetime history of TBI with LOC (number and severity of injury, age of first injury), and number and type of disability (vision, cognition, mobility, self-care, and/or independent living). RESULTS: Of the 6998 participants, 1325 reported lifetime history of TBI with LOC, and 1959 reported currently having one or more disabilities. When weighted, these represented 21.7% and 23.7% of Ohio's noninstitutionalized adult population, respectively. Adults with a history of TBI with LOC showed greater odds of any disability compared with adults with no history (odds ratio = 2.49; 95% confidence interval = 1.97-3.15). The likelihood of having any and each type of disability increased as the number of TBIs or the severity of worst TBI increased, regardless of sustaining first TBI before or after the age of 15 years. CONCLUSIONS: Lifetime history of TBI with LOC is significantly associated with disability among Ohio adults. Further research on the natural course of the relation and preventive strategies is warranted.

Test-Retest Reliability of Traumatic Brain Injury Outcome Measures: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: Evaluate the test-retest reliability of measures that comprise the Traumatic Brain Injury Model Systems follow-up data set. PARTICIPANTS: A total of 224 persons with a moderate-severe traumatic brain injury (TBI) enrolled in the Traumatic Brain Injury Model Systems National Database. DESIGN: Following standard administration of the follow-up interview, a second interview was administered 14 to 28 days later using the same interviewer and the same mode of administration. MAIN MEASURES: Traumatic Brain Injury Model Systems follow-up interview that includes 66 variables comprised (a) single item measures of demographics; employment; general health as well as specific health conditions; rehospitalization; tobacco, alcohol, and other drug use; transportation; and mental health and (b) multi-item instruments: FIM; Participation Assessment With Recombined Tools-Objective; Disability Rating Scale; Glasgow Outcome Scale-Extended; Supervision Rating Scale; Satisfaction With Life Scale; TBI Quality of Life Anxiety and Depression items; and The Ohio State University TBI Identification Method. RESULTS: Intraclass correlation coefficient values ranged from 0.65 to 0.99, weighted kappa values ranged from 0.54 to 0.99, and kappa values ranged from 0.43 to 1.00. Four kappa/weighted kappa estimates fell below 0.60: arrested, psychiatric hospitalization, number of days not in good physical health, and rating of general emotional health. CONCLUSIONS: With few exceptions, good to excellent test-retest reliability estimates were obtained. The findings support the use of these measures in prior and future studies and indicate that persons with moderate-severe TBI can provide reliable self-report.

Obtaining a History of Childhood Traumatic Brain Injury Using the Ohio State University TBI Identification Method to Elicit Adult Recall.

OBJECTIVE: To investigate the concordance between medically documented childhood traumatic brain injury (TBI) and recall of same by adults aged 35 years. PARTICIPANTS: A total of 962 birth cohort members from the Christchurch Health and Development Study available at the 35-year follow-up. MAIN MEASURES: Childhood TBI information prospectively collected yearly over ages 0 to 15 years as part of the Christchurch Health and Development Study. At age 35 years, cohort members were administered the Ohio State University TBI Identification Method (OSU TBI-ID) to elicit recall of TBIs with loss of consciousness (LOC). RESULTS: Ninety-four individuals reported 116 TBI events. Twenty-five TBI events resulting in LOC, 17 (68%) were recalled (true positives) and 8 (32%) were not recalled (false negatives). LOC was incorrectly recalled for 56 events (false positives), but 868 individuals correctly recalled no TBI event (no LOC). A further 35 events were (correctly) recalled for which a TBI had been recorded but no LOC (true negatives; 91.8%). IMPLICATIONS: We evaluated the utility of the OSU TBI-ID to identify adult recall of childhood TBI with LOC occurring 19 to 35 years earlier. Most of the cohort accurately reported whether or not they had experienced a medically attended TBI with LOC, indicating that a positive result from the OSU TBI-ID provides useful screening information.

Another Look at the PART-O Using the Traumatic Brain Injury Model Systems National Database: Scoring to Optimize Psychometrics.

OBJECTIVE: To integrate previous approaches to scoring the Participation Assessment with Recombined Tools-Objective (PART-O) in a unidimensional scale. DESIGN: Retrospective analysis of PART-O data from the Traumatic Brain Injury Model Systems. SETTING: Community. PARTICIPANTS: Data from individuals (N=469) selected randomly from participants who completed 1-year follow-up in the Traumatic Brain Injury Model Systems were used in Rasch model development. The model was subsequently tested on data from additional random samples of similar size at 1-, 2-, 5-, 10-, and >15-year follow-ups. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: PART-O. RESULTS: After combining items for productivity and social interaction, the initial analysis at 1-year follow-up indicated relatively good fit to the Rasch model (person reliability=.80) but also suggested item misfit and that the 0-to-5 scale used for most items did not consistently show clear separation between rating levels. Reducing item rating scales to 3 levels (except combined and dichotomous items) resolved these issues and demonstrated good item level discrimination, fit, and person reliability (.81), with no evidence of multidimensionality. These results replicated in analyses at each additional follow-up period. CONCLUSIONS: Modifications to item scoring for the PART-O resulted in a unidimensional parametric equivalent measure that addresses previous concerns about competing item relations, and it fit the Rasch model consistently across follow-up periods. The person-item map shows a progression toward greater community participation from solitary and dyadic activities, such as leaving the house and having a friend through social and productivity activities, to group activities with others who share interests or beliefs.

Prevalence of Self-Reported Lifetime History of Traumatic Brain Injury and Associated Disability: A Statewide Population-Based Survey.

OBJECTIVE: To investigate the prevalence of all severities of traumatic brain injury (TBI), regardless of treatment setting, and their associated negative outcomes. PARTICIPANTS: A total of 2701 adult Coloradoans. DESIGN: A statewide, population-based, random digit-dialed telephone survey. MAIN MEASURES: The lifetime history of TBI was assessed by a modification of the Ohio State University TBI Identification Method; activity limitation and life satisfaction were also assessed. RESULTS: The distribution of self-reported lifetime injury was as follows: 19.8%, no injury; 37.7%, injury but no TBI; 36.4%, mild TBI; and 6.0%, moderate-severe TBI. Of those reporting a TBI, 23.1% were hospitalized, 38.5% were treated in an emergency department, 9.8% were treated in a physician's office, and 27.5% did not seek medical care. A clear gradient of activity limitations and low life satisfaction was seen, with the highest proportions of these negative outcomes occurring in people reporting more severe TBI and the lowest proportions in those not reporting a TBI. Approximately twice as many people reported activity limitations and low life satisfaction after nonhospitalized TBI compared with hospitalized TBI. CONCLUSIONS: This investigation highlights the seriousness of TBI as a public health problem and the importance of including all severities of TBI, no matter where, or if treated, in estimating the prevalence of disability co-occurring with TBI.

Risk of Negative Outcomes After Traumatic Brain Injury: A Statewide Population-Based Survey.

OBJECTIVE: To investigate the rates of negative outcomes associated with all severities of traumatic brain injury (TBI), treated in all settings or not treated at all, in comparison to the general population. PARTICIPANTS: Coloradoans without injury, with injury but no TBI, with mild TBI but no loss of consciousness (LOC), mild TBI with LOC, moderate TBI, or severe TBI. DESIGN: Statewide population-based survey. MAIN MEASURES: Computer-assisted, modified Ohio State University TBI Identification Method; Behavioral Risk Factor Surveillance System and National Health Interview Survey questions; Satisfaction with Life Scale; and postconcussive symptoms. RESULTS: Up to 42.5% of participants reported a lifetime history of at least 1 TBI. Multiple negative outcomes were found to increase in prevalence in a stepwise fashion in association with greater TBI severity, with the clearest patterns observed for disability, poor life satisfaction, and impaired memory. CONCLUSIONS: Traumatic brain injury was found to be associated with disability and other negative outcomes in a general population survey. This study does not allow us to examine the proximate causes of disability, but it suggests that TBI may serve to both cause disability directly and exacerbate the influence of other etiologies. These relations should be examined in subsequent studies.

Trajectories of life satisfaction after traumatic brain injury: Influence of life roles, age, cognitive disability, and depressive symptoms.

OBJECTIVES: (a) Identify life satisfaction trajectories after moderate to severe traumatic brain injury (TBI); (b) establish a predictive model for these trajectories across the first 5 years postinjury; and (c) describe differences in these life satisfaction trajectory groups, focusing on age, depressive symptoms, disability, and participation in specific life roles. RESEARCH METHOD: Analysis of the longitudinal TBI Model Systems National Database was performed on data collected prospectively at 1-, 2-, and 5-years post-TBI. Participants (n = 3,012) had a moderate to severe TBI and were 16 years old and older. RESULTS: Four life satisfaction trajectories were identified across the first 5 years postinjury, including: stable satisfaction, initial satisfaction declining, initial dissatisfaction improving, and stable dissatisfaction. Age, depressive symptoms, cognitive disability, and life role participation as a worker, leisure participant, and/ or religious participant at 1-year postinjury significantly predicted trajectory group membership. Life role participation and depressive symptoms were strong predictors of life satisfaction trajectories across the first 5 years post-TBI. CONCLUSIONS: The previously documented loss of life roles and prevalence of depression after a moderate to severe TBI make this a vulnerable population for whom low or declining life satisfaction is a particularly high risk. Examining individual life role participation may help to identify relevant foci for community-based rehabilitation interventions or supports.

Preinjury predictors of life satisfaction at 1 year after traumatic brain injury.

OBJECTIVE: To investigate the predictive value of preinjury factors for satisfaction with life (SWL) at 1-year posttraumatic brain injury (TBI). DESIGN: Secondary analysis of prospective, longitudinal registry using data collected during inpatient rehabilitation and at 1-year post-TBI. SETTING: Fifteen specialized brain injury units providing acute rehabilitation care as part of the Traumatic Brain Injury Model Systems (TBIMS) program. PARTICIPANTS: Community-dwelling persons (N=444) with moderate to severe TBI aged 16 to 64 years enrolled in the TBIMS program between October 2007 and October 2008 with 1-year follow-up data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Satisfaction With Life Scale (SWLS). RESULTS: Hierarchical stepwise linear regression revealed that injury-related and demographic variables did not contribute significantly to the explained variance in SWLS scores. In contrast, the preinjury functioning (education, productivity/employment) and preinjury condition (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI) blocks each contributed significantly to the explained variance in SWLS scores. Preinjury functioning accounted for 2.9% of the variance and preinjury conditions for 3.8%. CONCLUSIONS: Although their contributions are small, preinjury functioning and preinjury conditions are important to consider in the prediction of SWL post-TBI. Educational level and history of psychiatric and other premorbid difficulties are particularly important for clinicians to consider when implementing or developing interventions for persons with moderate to severe TBI.

Prevalence of traumatic brain injury among prisoners in South Carolina.

OBJECTIVE: To determine lifetime prevalence of traumatic brain injury (TBI) in a statewide sample of prisoners. DESIGN: Retrospective and cross-sectional cohort study. PARTICIPANTS: Stratified random sample of prisoners scheduled to be released by release type for each gender (275 men and 267 women with completed sentences and 19 men and 15 women granted parole) and a random sample of prisoners by gender with lifetime or death sentences (26 men and 34 women). PRIMARY MEASURE: Weighted prevalence of TBI. In-person interviews ascertained history of TBI using a customized version of the Ohio State University TBI Identification Method. RESULTS: Sixty-five percent of male releases and nonreleases, and 72% and 73% of female releases and nonreleases, reported at least 1 TBI with an alteration of consciousness. Forty-two percent of male releases and 50% of nonreleases, and 50% of female releases and 33% of nonreleases, reported at least 1 TBI with loss of consciousness. Thirty-five percent of male releases and 42% of nonreleases, and 55% of female releases and 58% of nonreleases, reported ongoing symptoms from TBI. CONCLUSIONS: A substantial proportion of prisoners reported having experienced a TBI during their lifetime. The ongoing TBI symptoms reported by prisoners may impact their success on release.

Major and minor depression after traumatic brain injury.

OBJECTIVE: To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation. DESIGN: Observational prospective study with a 2-wave longitudinal component. SETTING: Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale. RESULTS: Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI. CONCLUSIONS: Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups.

Development of the participation assessment with recombined tools-objective for use after traumatic brain injury.

OBJECTIVE: To develop a new measure, the Participation Assessment With Recombined Tools-Objective (PART-O), based on items from 3 participation instruments. DESIGN: Instrument development based on survey research. SETTING: Community. PARTICIPANTS: Adults (N=400) with traumatic brain injury (TBI) 1 to 15 years postinjury, recruited from 8 TBI Model Systems (TBIMS). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Community Integration Questionnaire version 2; Participation Objective, Participation Subjective; Craig Handicap Assessment and Reporting Technique; PART-O. RESULTS: Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments, a set of 24 items was developed that covered a broad range of participation content and formed a measure with person separation of 2.47, person reliability of .86, item spread of 4.25 logits, item separation of 11.36, and item reliability of .99. Items were well targeted on the sample with only 1 item misfitting. The PART-O showed expected relationships with measures of impairment, activity limitations, and subjective well-being. CONCLUSIONS: The 24-item PART-O is an acceptable measure of objective participation for persons with moderate and severe TBI. It has been adopted as the measure of participation in the TBIMS.

Measuring participation enfranchisement.

OBJECTIVE: To reflect the perspectives of rehabilitation stakeholders in a measure of participation enfranchisement that can be used by people with and without disabilities. DESIGN: Survey. SETTING: Community settings. PARTICIPANTS: We pilot-tested a draft instrument with 326 adults who had sustained stroke, spinal cord injury, traumatic brain injury, or other disabling condition, as well as a general population sample. We administered a revised version of the instrument to a statewide sample drawn from the 2006 Colorado Behavioral Risk Factors Surveillance System that included persons with (N=461) and without (N=451) self-identified activity limitations. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Participation enfranchisement. RESULTS: We used multidimensional scaling, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), followed by rating scale analysis to evaluate the psychometric properties of the instrument. EFA identified 3 participation enfranchisement factors that describe perceived choice and control, contributing to one's community, and feeling valued; the factors were supported marginally by CFA. Rating scale analysis revealed marginal person separation and no misfitting items. CONCLUSIONS: Participation enfranchisement constitutes a new, previously unmeasured aspect of participation-one that addresses subjective perceptions rather than objective performance-with items that are clearly distinct from more generalized satisfaction with participation. The 19 enfranchisement items describe aspects of participation that may prove useful in characterizing longer-term rehabilitation outcomes.

Advancing the measurement of participation.

The authors of 3 articles in this issue have collaborated in an effort to advance the conceptualization and measurement of participation. These articles offer (1) a new tool for measuring participation, the Participation Assessment with Recombined Tools-Objective (PART-O), which combines items from widely used instruments in traumatic brain injury rehabilitation research; (2) 2 methods of scoring 17 items of PART-O, assessing relatively objective social role performance and yielding 3 subscale scores, as well as 2 alternative total scores (including 1 incorporating the concept of balance among types of participation), and (3) 19 enfranchisement items assessing the degree to which people with disability perceive they have the freedom to engage in social roles of their choosing while being accepted and valued by others.

Comparison of scoring methods for the participation assessment with recombined tools-objective.

OBJECTIVE: To develop and compare 2 scoring algorithms for a measure of participation, the Participation Assessment with Recombined Tools-Objective (PART-O) based on the assumption that more participation is better versus an alternative that reflects balance in domains of participation. DESIGN: Survey. SETTING: Community settings. PARTICIPANTS: Three groups of participants under the age of 65 years were included: (1) persons with spinal cord injury, traumatic brain injury, stroke, and other disorders who are commonly treated in acute rehabilitation settings (n=220), and (2) participants from the general population who did (n=366) or (3) did not (n=284) self-report limitations indicative of a disability who participated in the 2006 Colorado Behavioral Risk Factor Surveillance System (N=870). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: PART-O. RESULTS: We developed PART-O subscores using a consensus process and then evaluated them empirically. We combined subscores using 2 contrasting algorithms, one using average scores and the other reflecting the amount of participation and variation in participation across 3 domains. The algorithms for the total scores yielded normal distributions in all 3 samples and were equally sensitive to the impact of disability. While strongly correlated, about 30% of the variance of the 2 total scores was not shared. CONCLUSIONS: Two scoring algorithms for the PART-O illustrate contrasting perspectives of the construct of participation. The 2 algorithms may be used in future studies to expand our understanding of the construct of participation.

Neighborhood characteristics and outcomes after traumatic brain injury.

OBJECTIVE: To determine the extent to which characteristics of a person's neighborhood contribute to outcomes after traumatic brain injury (TBI). DESIGN: Prospective cohort. SETTING: A specialized brain injury unit providing acute rehabilitation care. PARTICIPANTS: A consecutive sample of participants (N=200) in the Traumatic Brain Injury Model Systems (TBIMS) longitudinal study: 100 participants were 2 years postinjury, and 100 participants were 5 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: U.S. Census Bureau block group descriptors of economic and social characteristics and initial and follow-up data from the TBIMS national dataset including the Glasgow Outcome Scale-Extended (GOS-E) and Satisfaction With Life Scale (SWLS). RESULTS: Economic and social characteristics of a person's neighborhood accounted for additional variance in outcomes beyond what could be accounted for by individual characteristics, including demographic, premorbid, and injury-related measures; concurrent measures of functioning; and the persons's perception of environmental influences. Individual characteristics predicted a substantial proportion of the variance in the GOS-E (69%); neighborhood characteristics contributed an additional 1.5%. Individual characteristics predicted 33.3% of the variance in SWLS, with neighborhood characteristics accounting for an additional 6.9%. CONCLUSIONS: For both outcomes, a small but important proportion of the variance accounted for by neighborhood indices was unique to these environmental influences and was not accounted for by individual indices, including concurrent measures of functioning and the individual's perception of environmental influences. Further investigations of how neighborhood factors affect outcomes after TBI are warranted.