Workers' risk of unemployment after traumatic brain injury: a normed comparison.

We examined, among those persons working preinjury, the risk of unemployment 1 year after traumatic brain injury (TBI) relative to expected risk of unemployment for the sample under a validated risk-adjusted econometric model of employment in the U.S. population. Results indicate that 42% of TBI cases were unemployed versus 9% expected, relative risk (RR) = 4.5, 95% confidence interval (CI) (4.12, 4.95). The relative risk for unemployment was higher among males, those with higher education, persons with more severe injuries, and more impaired early neuropsychological or functional status. Difference in unemployment rates gave similar results for gender, severity of injury, and early neuropsychological and functional status. However, for education, the excess was smaller among those more highly educated, but the unemployment rate in the more highly educated in the general population was sufficiently small to yield a larger relative risk. In conclusion, after accounting for underlying risk of unemployment in the general population, unemployment is substantially higher after TBI for people who were employed when they were injured. The differential employment status varies depending on demographics, severity of brain injury, early functional outcome, and neurobehavioral indicators. For characteristics such as education, associated with rates of unemployment in the general population, different methods used to compare the rates may yield different results.

Self-report of extent of recovery and barriers to recovery after traumatic brain injury: a longitudinal study.

OBJECTIVE: To examine the perspective of survivors of traumatic brain injury (TBI) regarding the extent and nature of their recovery over time. DESIGN: Inception cohort, longitudinal study. SETTING: Level I trauma center. PARTICIPANTS: One hundred fifty-seven consecutively hospitalized individuals with TBI (mean age, 36.1 yr; 80% men) with a broad range of injury severity. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants reported the extent of their recovery and barriers to full recovery at 1, 6, and 12 months. RESULTS: Participants reported a median return to normal at the 3 follow-up times of 65%, 80%, and 85%. After 1 month, self-reported extent of recovery correlated well with performance on the Glasgow Outcome Scale (p <.001 at 6 and 12 mo) and Wechsler Adult Intelligence Scale Performance IQ (p =.001 at 12 mo). The major reported barrier to recovery was physical difficulties, which constituted over half of the concerns at all time periods. Report of physical-related concerns decreased significantly (p =.002) over time whereas cognition-related concerns increased significantly (p =.02). CONCLUSION: Brain injury survivors consider themselves to have greater recovery than previously reported by clinicians or family members, consider physical problems a significant factor in their recovery, and appear to become more aware of cognitive impairments over time.

Utility of a composite measure to detect problematic alcohol use in persons with traumatic brain injury.

OBJECTIVES: To examine factors complicating the study of alcohol-related effects in traumatic brain injury (TBI) patients and to evaluate a composite measure to categorize such patients according to degree of alcohol-related problems. DESIGN: Inception cohort. SETTING: Level I trauma center. PATIENTS: Consecutively hospitalized adult TBI patients (n = 156; 73% men; 87% Caucasian; mean age, 30yr; mean education, 12yr). Selection criteria required objective evidence of brain trauma; minimum survival of 1 month postinjury; age 15 years or older; and English speaking. MAIN OUTCOME MEASURES: An index of problematic drinking based on a measure created by combining blood-alcohol level, quantity-frequency of consumption, and the Short Michigan Alcoholism Screening Test. Preinjury characteristics were obtained through structured interview. RESULTS: Participants with highly problematic drinking showed poorer premorbid psychosocial functioning, including lower educational attainment, greater likelihood of problems with the law, lower perceived social support, and greater prevalence of other substance abuse. CONCLUSION: The composite index is useful in identifying problematic drinkers among TBI patients. Results have implications for interpreting and planning research on the role of alcohol in TBI outcomes.

Functional status examination: a new instrument for assessing outcome in traumatic brain injury.

The Functional Status Examination (FSE) is a new measure designed to evaluate change in activities of everyday life as a function of an event or illness, including traumatic brain injury. The measure covers physical, social, and psychological domains. The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to preinjury functioning. Based on 133 prospectively studied patients with moderate to severe traumatic brain injury, the FSE has favorable psychometric properties including good test-retest reliability (r = 0.80) and close correspondence of assessments provided by the patient and their significant other (SO; r = 0.80). The FSE correlated significantly with each of three severity indices with closest relationships occurring between the FSE assessed by the SO and posttraumatic amnesia (r = 0.76). The FSE assessed by the SO was significantly (p < 0.05) more closely related to each severity index than the Glasgow Outcome Scale (GOS) or Sickness Impact Profile and, for two of the three indices, than the SF-36. All measures showed significant change from 1 to 6 months after injury with the FSE showing the largest effect sizes. The FSE is significantly related to important constructs such as family burden, SO depression, and sacrifices the family makes, as well as overall indices of recovery and satisfaction with level of functioning. The latter relationships are significantly stronger than for the GOS. The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.

Mild head injury: facts and artifacts.

While most would agree that mild traumatic brain injury (TBI) is associated with early neuropsychological problems, disagreement exists regarding their persistence and whether they are the cause of the disabilities experienced by some people. The aim of this study was to examine how the criteria used to define mild TBI and how the pre-injury characteristics of people affect their neuropsychological outcome. A total of 157 unselected hospitalized cases with Glasgow Coma Scale scores of 13-15 and 109 trauma controls were prospectively recruited and administered a number of cognitive measures at 1 month and 12 months after injury. The results indicated early impairments that decreased with time and the stringency of the definition of 'mild' TBI. The contribution of demographics was usually significant and often stronger than the mild TBI effect. Subtle variation of the demographics of the brain injured or the comparison subjects can be sufficient to mimic or mask mild brain injury effects.

Neuropsychological effects of valproate in traumatic brain injury: a randomized trial.

OBJECTIVES: To examine the neuropsychological side effects of valproate (VPA) given to prevent posttraumatic seizures. METHODS: In a randomized, double-masked, parallel group clinical trial, we compared the seizure prevention and neuropsychological effects of 1 or 6 months of VPA to 1 week of phenytoin. We studied 279 adult subjects who were randomized within 24 hours of injury and examined with a battery of neuropsychological measures at 1, 6, and 12 months after injury. We examined drug effects cross-sectionally at 1, 6, and 12 months and longitudinally by examining differential change from 1 to 6 months and from 6 to 12 months as a function of protocol-dictated changes in treatment. RESULTS: No significant adverse or beneficial neuropsychological effects of VPA were detected. CONCLUSIONS: Valproate (VPA) appears to have a benign neuropsychological side effects profile, making it a cognitively safe antiepileptic drug to use for controlling established seizures or stabilizing mood. However, based on this study, VPA should not be used for prophylaxis of posttraumatic seizures because it does not prevent posttraumatic seizures, there was a trend toward more deaths in the VPA groups, and it did not have positive effects on cognition.

Emotional and behavioral adjustment after traumatic brain injury.

OBJECTIVES: To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. DESIGN: Longitudinal evaluation of adjustment from 1 month to 1 year after injury. SETTING: Level I trauma center at a university hospital. PATIENTS: One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. MAIN OUTCOME MEASURES: Katz Adjustment Scale (KAS). RESULTS: The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. CONCLUSIONS: These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.

Alcohol use before and after traumatic head injury.

STUDY OBJECTIVE: To determine (1) the significance of blood alcohol level in the emergency department in history of alcohol abuse and (2) the significance of habitual alcohol use in head-injured patients before and after injury. DESIGN: Inception cohort study with 1-year follow-up. SETTING: Level I trauma center. PARTICIPANTS: One hundred ninety-seven hospitalized adult head-injury survivors with a broad spectrum of head-injury severity. RESULTS: Alcohol use and behavioral problems associated with alcohol use were assayed before injury and in the month and year after injury. The patients' blood alcohol levels in the ED were also examined. Preinjury alcohol abuse was frequent; 42% of the subjects were legally intoxicated while in the ED. The amount of drinking and magnitude of reported preinjury alcohol problems decreased soon after the injury but was followed by an increase by 1 year, although the amount of drinking did not return to the preinjury level (P < .0001). Patients with more severe head injuries decreased their drinking more than did those with less severe head injuries. The patients' blood alcohol levels in the ED were a good indicator of the magnitude of their preinjury alcohol problems (r = .51 to .59; each, P < .001). CONCLUSION: Preinjury habitual alcohol abuse is frequent in head-injured patients. Blood alcohol levels in the ED are indicative of history of problem drinking and might serve as a basis for treatment referral. The first weeks after injury in hospitalized patients may provide an opportunity to begin interventions because head-injured patients drink less at that time.

Classification and regression trees (CART) for prediction of function at 1 year following head trauma.

A cohort of 514 hospitalized head-injury survivors was identified based on their injury and 448 (87%) of them were followed for 1 year. Comprehensive neurobehavioral testing was performed 1 month and 1 year after injury. The authors developed predictions of six neuropsychological and two psychosocial outcomes 1 year after head injury. Prediction trees are presented for verbal IQ, Halstead's Impairment Index, and work status at 1 year. Early predictors of neurobehavioral outcome in survivors are similar to previously reported predictors of mortality. Extent (both depth and length) of coma and age are the medical and demographic variables most predictive of late outcome. Adding 1-month scores substantially improves prediction of neuropsychological variables. The classification and regression tree is a useful technique for predicting long-term outcome in patients with head injury. The trees are simple enough to be used in a clinical setting and, especially with 1-month scores, predictions are accurate enough for clinical utility.

One year psychosocial outcome in head injury.

Psychosocial outcome at one year post-injury was examined prospectively in 466 hospitalized head-injured subjects, 124 trauma controls, and 88 friend controls. The results indicate that head injury is associated with persistent psychosocial limitations. However, the presence and extent of limitations are related to the demographics of the population injured, to other system injuries sustained in the same accident, and particularly to the severity of the head injury. More severe head injuries are associated with limitations implying greater dependence on others including poorer Glasgow Outcome Scale (GOS) ratings, dependent living, unemployment, low income, and reliance on family and social subsidy systems. Head injury severity is more closely related to more objective indices of psychosocial outcome (e.g., employment) than to self-perceived psychosocial limitations, such as measured by the Sickness Impact Profile (SIP).

Employment following traumatic head injuries.

OBJECTIVE: Determine rates of, and factors predictive of, return to work in patients with civilian traumatic head injuries. DESIGN: Inception cohort study with 1- to 2-year follow-up. SETTING: Hospitalized patients in a level I trauma center. PATIENTS: Three hundred sixty-six hospitalized head-injured subjects who were workers before injury and 95 comparison subjects participated in prospective, longitudinal investigations of employment following head injury. Head-injured and comparison subjects were similar on basic demographics and preinjury employment status. The comparison subjects consisted of patients who sustained traumatic injury to the body but not to the head. MAIN OUTCOME MEASURE: Time taken to return to work following head injury. RESULTS: Survival methodology was used for analysis. Whether patients returned to work and when related to both the characteristics of the injured patients (eg, education, preinjury work history), the severity of head injury and associated neuropsychologic problems, and severity of other system injuries. More precise predictions were possible using the multivariate model. CONCLUSIONS: The present study provides a means of assessing employment potential predictively. This can be useful for clinical and research purposes. The results should be used cautiously and should stimulate discussions of appropriate use of services and resources to meet individual patients' needs.

Psychosocial outcome in patients with moderate to severe head injury: 2-year follow-up.

Psychosocial outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. We conclude that moderate and severe head injuries have a significant long-term impact on psychosocial functioning. More specifically, although there is an increase over time in the number of subjects who resume former levels of activity, many moderate to severely head-injured people remain unable to work, support themselves financially, live independently and participate in pre-injury leisure activities at least up to 2 years post-injury. Initially, self-perceived limitations in everyday functioning are widespread, with physical functioning being of primary concern. Over time, there is improvement in both physical and psychosocial areas. However, in spite of improvement, difficulties in psychosocial functioning become dominant later due to greater improvement in the physical area. This study gives no evidence of general increase in emotional distress with increasing time since injury.

Neurobehavioral effects of phenytoin prophylaxis of posttraumatic seizures.

In order to determine potential negative neurobehavioral effects of phenytoin given to prevent the development of posttraumatic seizures, 244 subjects were randomized to phenytoin or placebo. They received neurobehavioral assessments at 1 and 12 months postinjury while receiving their assigned drug and at 24 months while receiving no drugs. In the severely injured, phenytoin significantly impaired performance at 1 month. No significant differences were found as a function of phenytoin in the moderately injured patients at 1 month or in either severity group at 1 year. Patients who stopped receiving phenytoin according to protocol between 1 and 2 years improved more than corresponding placebo cases on several measures. We conclude that phenytoin has negative cognitive effects. This, combined with lack of evidence for its effectiveness in preventing posttraumatic seizures beyond the first week, raises questions regarding its use for long-term prophylaxis. Our findings do not negate phenytoin's proven efficacy in controlling established seizures nor do they indicate that its cognitive effects are worse than other anticonvulsant drugs.

Neuropsychological recovery in patients with moderate to severe head injury: 2 year follow-up.

Neuropsychological outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. Based on the results we conclude: (1) there is marked impairment of a broad spectrum of neuropsychological functions at 1, 12, and 24 months postinjury; (2) coma length is significantly related to neuropsychological status at all three time periods, although the relationship is weaker at 12 and 24 months; (3) marked improvement in all functions occurs in the first year, while recovery in the second year appears more specific and may depend on the severity of the injury and type of function; (4) practice effects and variability over repeated measures cause difficulties in determining recovery and need to be addressed with larger samples.

General versus disease-specific measures. Further work on the Sickness Impact Profile for head injury.

Three modifications devised to make the Sickness Impact Profile more sensitive to head injury are evaluated in 202 head-injured and 132 general trauma patients 1 month and 12 months after injury. The modifications consist of adding items, deleting nonapplicable items, and reweighting areas of function. Each of the modifications, and especially all three combined, slightly but significantly improve discrimination of head-injured and comparison subjects and increase correlations with neurologic and neuropsychologic severity indexes. These slight improvements occur more often at 12 months than at 1 month and among those without rather than with pre-existing conditions. No improvements are found in the ability to classify patients into subgroups. The modifications fail to make improvements sufficiently large or consistent to provide a practical advantage over the SIP. The standard SIP provides a reasonable measure of psychosocial functioning following head injury. It relates to head injury and other system injury severity and reflects recovery with time. The SIP score relates to emotional functioning even after injury severity has been taken into account. Until other factors, such as emotional status and responses style, are better controlled, little benefit is likely to be obtained from creating disease-specific psychosocial measures.

Memory and head injury severity.

One hundred and two consecutive head injured patients were studied at 1 and 12 months after injury. Their performances were compared with a group of uninjured friends. The results indicate that impairment in memory depends on the type of task used, time from injury to testing, and on the severity of head injury (that is, degree of impaired consciousness). Head injury severity indices are more closely related to behavioural outcome early as compared with later after injury. At 1 year, only those with deep or prolonged impaired consciousness (as represented by greater than 1 day of coma, Glasgow Coma Scale of 8 or less, and post traumatic amnesia of 2 weeks or greater) are performing significantly worse than comparison subjects.