Executive function improvement in response to meta-cognitive training in chronic mTBI / PTSD.

Objective: We tested Goal Management Training (GMT), which has been recommended as an executive training protocol that may improve the deficits in the complex tasks inherent in life role participation experienced by those with chronic mild traumatic brain injury and post-traumatic stress disease (mTBI/PTSD). We assessed, not only cognitive function, but also life role participation (quality of life). Methods: We enrolled and treated 14 individuals and administered 10 GMT sessions in-person and provided the use of the Veterans Task Manager (VTM), a Smartphone App, which was designed to serve as a "practice-buddy" device to ensure translation of in-person learning to independent home and community practice of complex tasks. Pre-/post-treatment primary measure was the NIH Examiner, Unstructured Task. Secondary measures were as follows: Tower of London time to complete (cTOL), Community Reintegration of Service Members (CRIS) three subdomains [Extent of Participation; Limitations; Satisfaction of Life Role Participation (Satisfaction)]. We analyzed pre-post-treatment, t-test models to explore change, and generated descriptive statistics to inspect given individual patterns of change across measures. Results: There was statistically significant improvement for the NIH EXAMINER Unstructured Task (p < .02; effect size = .67) and cTOL (p < .01; effect size = .52. There was a statistically significant improvement for two CRIS subdomains: Extent of Participation (p < .01; effect size = .75; Limitations (p < .05; effect size = .59). Individuals varied in their treatment response, across measures. Conclusions and Clinical Significance: In Veterans with mTBI/PTSD in response to GMT and the VTM learning support buddy, there was significant improvement in executive cognition processes, sufficiently robust to produce significant improvement in community life role participation. The individual variations support need for precision neurorehabilitation. The positive results occurred in response to treatment advantages afforded by the content of the combined GMT and the employment of the VTM learning support buddy, with advantages including the following: manualized content of the GMT; incremental complex task difficulty; GMT structure and flexibility to incorporate individualized functional goals; and the VTM capability of ensuring translation of in-person instruction to home and community practice, solidifying newly learned executive cognitive processes. Study results support future study, including a potential randomized controlled trial, the manualized GMT and availability of the VTM to ensure future clinical deployment of treatment, as warranted.

The Impact of Complementary and Integrative Medicine Following Traumatic Brain Injury: A Scoping Review.

OBJECTIVE: To examine the evidence levels, study characteristics, and outcomes of nonpharmacologic complementary and integrative medicine (CIM) interventions in rehabilitation for individuals with traumatic brain injury (TBI). DATA SOURCES: MEDLINE (OvidSP), PubMed (NLM), EMBASE ( Embase.com ), CINAHL (EBSCO), PsycINFO (OvidSP), Cochrane Library (Wiley), and National Guidelines Clearinghouse databases were evaluated using PRISMA guidelines. The protocol was registered in INPLASY (protocol registration: INPLASY202160071). DATA EXTRACTION: Quantitative studies published between 1992 and 2020 investigating the efficacy of CIM for individuals with TBI of any severity, age, and outcome were included. Special diets, herbal and dietary supplements, and counseling/psychological interventions were excluded, as were studies with mixed samples if TBI data could not be extracted. A 2-level review comprised title/abstract screening, followed by full-text assessment by 2 independent reviewers. DATA SYNTHESIS: In total, 90 studies were included, with 57 001 patients in total. This total includes 2 retrospective studies with 17 475 and 37 045 patients. Of the 90 studies, 18 (20%) were randomized controlled trials (RCTs). The remainder included 20 quasi-experimental studies (2-group or 1-group pre/posttreatment comparison), 9 retrospective studies, 1 single-subject study design, 2 mixed-methods designs, and 40 case study/case reports. Guided by the American Academy of Neurology evidence levels, class II criteria were met by 61% of the RCTs. Included studies examined biofeedback/neurofeedback (40%), acupuncture (22%), yoga/tai chi (11%), meditation/mindfulness/relaxation (11%), and chiropractic/osteopathic manipulation (11%). The clinical outcomes evaluated across studies included physical impairments (62%), mental health (49%), cognitive impairments (39%), pain (31%), and activities of daily living/quality of life (28%). Additional descriptive statistics were summarized using narrative synthesis. Of the studies included for analyses, 97% reported overall positive benefits of CIM. CONCLUSION: Rigorous and well experimentally designed studies (including RCTs) are needed to confirm the initial evidence supporting the use of CIM found in the existing literature.

Patient-Reported Outcome of Functional Cognition for Traumatic Brain Injury: Item-Level Psychometrics.

A patient-reported functional cognition measure that can bridge neuropsychological tests and ecological validity is lacking. The purpose of this study was to present the initial item-level psychometrics of a functional cognition item bank, the Functional Cognition-Patient-Reported Outcome (FC-PRO). Confirmatory factor analysis, Rasch analysis, and convergent validity were conducted to establish item-level psychometrics of the FC-PRO item bank. Four of the six domains met essential unidimensionality criteria; all domains met rating scale criteria; domains had relatively few misfitting items (3%-13%); person reliability (.8-.92), and person strata (2.97-4.29) were satisfactory; the domains showed convergent validity for five of six domains. The FC-PRO showed adequate initial item-level psychometrics for researchers/clinicians to measure specific functional cognitive domains in patients with traumatic brain injury (TBI). This study provides the foundation for the development of future short forms, computer adaptive tests, and keyform recovery maps of patient-reported functional cognition to facilitate clinical utilization.

Effects of Vibration Training on Cognition and Quality of Life in Individuals With Multiple Sclerosis.

Background: Multiple sclerosis (MS) detrimentally affects cognition and quality of life (QOL). Interventions that can improve cognitive deficit and QOL in individuals with MS are desired. This pilot study investigated the possible effects of vibration training on improving cognition and QOL in individuals with MS. Methods: Eighteen adults with MS were randomized into 2 groups: training and control. The training group underwent 6 weeks of vibration training, and the control group maintained their normal lifestyle throughout the study. In both groups, before and after the training course, the disability status was evaluated by the Patient Determined Disease Steps scale and the Multiple Sclerosis Functional Composite (MSFC), cognitive function was assessed by the Behavior Rating Inventory of Executive Function-Adults (BRIEF-A) and the Buschke Selective Reminding Test (SRT), and QOL was gauged by the 36-item Short Form Health Survey (SF-36). Results: The training was well accepted by the participants, and no major adverse event was reported. All participants finished the entire protocol. Compared with the control group, the training group showed greater improvements in MSFC score, Metacognition Index score of the BRIEF, SRT score, and physical domain score of the SF-36. Conclusions: These results suggest that vibration training could be an effective alternative training paradigm to enhance cognition and QOL in individuals with MS, and they provide an encouraging base to conduct a large-scale clinical trial.

An overview of systematic reviews on the pharmacological randomized controlled trials for reducing intracranial pressure after traumatic brain injury.

BACKGROUND: There is a need for an overview of systematic reviews (SRs) examining randomized clinical trials (RCTs) of pharmacological interventions in the treatment of intracranial pressure (ICP) post-TBI. OBJECTIVES: To summarize pharmacological effectiveness in decreasing ICP in SRs with RCTs and evaluate study quality. METHODS: Comprehensive literature searches were conducted in MEDLINE, PubMed, EMBASE, PsycINFO, and Cochrane Library databases for English SRs through October 2020. Inclusion criteria were SRs with RCTs that examined pharmacological interventions to treat ICP in patients post-TBI. Data extracted were participant characteristics, pharmacological interventions, and ICP outcomes. Study quality was assessed with AMSTAR-2. RESULTS: Eleven SRs between 2003 and 2020 were included. AMSTAR-2 ratings revealed 3/11 SRs of high quality. Pharmacological interventions included hyperosmolars, neuroprotectives, anesthetics, sedatives, and analgesics. Study samples ranged from 7 to 1282 patients. Hyperosmolar agents and sedatives were beneficial in lowering elevated ICP. High bolus dose opioids had a more deleterious effect on ICP. Neuroprotective agents did not show any effects in ICP management. CONCLUSIONS: RCT sample sizes and findings in the SRs varied. A lack of detailed data syntheses was noted. AMSTAR-2 analysis revealed moderate to high quality in most SRs. Future SRs may focus on streamlined reporting of dosing and clearer clinical recommendations. PROSPERO-Registration: CRD42015017355.

Examining the Item-Level Factor Structure of the Behavior Rating Inventory of Executive Function-Adult Version Within a Traumatic Brain Injury Sample.

OBJECTIVE: To conduct the first item-level exploration of scale and index structure of the self-report Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A) in traumatic brain injury (TBI). DESIGN: This was an observational cross-sectional study design using secondary data. We conducted exploratory factor analyses (EFA) to explore the index structure and scale structure of the BRIEF-A. We conducted EFA with all 70 items of the BRIEF-A to examine the index structure. Based on the finding of index structure, we conducted EFA on the 30 items of the Behavioral Regulation Index (BRI) and the 40 items of the Metacognitive Index (MI). SETTING: Data were collected through 5 studies in outpatient and community settings in the southeast United States. PARTICIPANTS: Individuals (N=338) aged 18-89 years with a history of mild to severe TBI who were able to speak English fluently. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The BRIEF-A. RESULTS: The 2-factor structure aligned with the BRIEF-A manual at the index level. Scale structure for the MI (40 items) resulted in 1 factor, whereas the BRI (30 items) could be represented by either a 2- or 3-factor structure. The 2-factor structure of the BRI is more parsimonious and matched other factor analyses derived from the sum of scale items. CONCLUSIONS: We confirmed the manual designated index structure (BRI and MI) of the BRIEF-A but took precautions against using the 9 scales. Instead, we recommend using the 2 designated index scores and 2 newly identified composite scores representing Behavioral Control Trait and Emotional Control Trait.

Feasibility of Yoga to Improve Symptoms in Individuals With Severe, Chronic Traumatic Brain Injury: A Mixed-Methods Case Series.

CONTEXT: People with severe traumatic brain injury (TBI) experience lifelong sequelae that affect physical, cognitive, and mental health. In other populations, yoga has shown potential to alleviate insomnia, pain, and depression and to improve cognition. OBJECTIVE: The study intended to investigate the feasibility of a six-week, group-yoga intervention for adults with severe chronic TBI, focusing on sleep, pain, mood, and executive function. DESIGN: The research team performed a feasibility study using a mixed-methods, case-series design. SETTING: The study recruited participants by distributing flyers to local communities and TBI support groups. PARTICIPANTS: Participants were two people with severe, chronic, TBI. INTERVENTION: The intervention was a six-week course of group yoga, with 70-minute classes twice a week. OUTCOME MEASURES: The study assessed outcomes at baseline and postintervention using validated measures to assess executive function, mood, sleep, and pain: the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A), Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), and Neuropathic Pain Scale (NPS). A semistructured interview was conducted during the week postintervention to obtain qualitative data. RESULTS: The study had a 100% retention rate, a 91.67% attendance rate, and high satisfaction. One participant demonstrated improvement in all outcomes, while the other showed mixed results. Depression showed the most consistent improvement, 47.2% on average. For insomnia, one participant showed improved sleep at 14.29%. The qualitative data demonstrated positive changes in cognition, mood, sleep, and pain. CONCLUSIONS: A six-week group yoga intervention is feasible and appears to be beneficial in alleviating symptoms, especially depression and insomnia, in people with severe chronic TBI. A longer intervention period was suggested by the participants.

Smartphone Application for Measuring Community Participation in Veterans With Traumatic Brain Injury.

The goal in the rehabilitation of veterans with mild traumatic brain injury (mTBI) is to improve community participation. A tool that can objectively measure community participation is lacking. The aims of this study are to evaluate the feasibility of a smartphone application (app) called MOVES to objectively measure community participation; and compare MOVES with a self-report questionnaire, and differences between veterans with mTBI and civilians without TBI. It is a 6-week parallel observational study, which included seven veterans with blast-related mTBI and five civilians without TBI. The measures include MOVES, Participation Assessment with Recombined Tools-Objective (self-report participation measure), Satisfaction Questionnaire, and Perceived Accuracy Daily Logs. Participants were mostly satisfied using the MOVES app with 75% retention rate. Perceived accuracy of the MOVES app was 90%, while the two groups showed similar discrepancies between the PART-O and the MOVES (52% vs. 53%). The MOVES app is a feasible option to objectively measure community participation. Self-report was discrepant from the MOVES app for both groups.

Use of mHealth Technology for Patient-Reported Outcomes in Community-Dwelling Adults with Acquired Brain Injuries: A Scoping Review.

The purpose of our scoping review was to describe the current use of mHealth technology for long-term assessment of patient-reported outcomes in community-dwelling individuals with acquired brain injury (ABI). Following PRISMA guidelines, we conducted a scoping review of literature meeting these criteria: (1) civilians or military veterans, all ages; (2) self-reported or caregiver-reported outcomes assessed via mobile device in the community (not exclusively clinic/hospital); (3) published in English; (4) published in 2015-2019. We searched Ovid MEDLINE(R) < 1946 to 16 August 2019, MEDLINE InProcess, EPub, Embase, and PsycINFO databases for articles. Thirteen manuscripts representing 12 distinct studies were organized by type of ABI [traumatic brain injury (TBI) and stroke] to extract outcomes, mHealth technology used, design, and inclusion of ecological momentary assessment (EMA). Outcomes included post-concussive, depressive, and affective symptoms, fatigue, daily activities, stroke risk factors, and cognitive exertion. Overall, collecting patient-reported outcomes via mHealth was feasible and acceptable in the chronic ABI population. Studies consistently showed advantage for using EMA despite variability in EMA timing/schedules. To ensure best clinical measurement, research on post-ABI outcomes should consider EMA designs (versus single time-point assessments) that provide the best timing schedules for their respective aims and outcomes and that leverage mHealth for data collection.

Measurement Properties of the MPAI-4 in Veterans With mTBI.

OBJECTIVES: To determine whether the measurement properties of the Mayo-Portland Adaptability Inventory Version 4 (MPAI-4) and its participation index (M2PI), which have been adopted as 2 outcome measures in the Veterans Health Administration (VHA) National Polytrauma Rehabilitation Systems of Care, are adequate in veterans with mild traumatic brain injury (mTBI). DESIGN: Cross-sectional. SETTING: Outpatient rehabilitation. PARTICIPANTS: Postdeployment veterans with blast-related mTBI (N=177). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Mayo-Portland Adaptability Inventory Version 4 (MPAI-4) and Community Integration Questionnaire (CIQ). RESULTS: The unidimensional factor structure of the MPAI-4 total and 3 index scores (abilities, adjustment, participation) were confirmed. Eight of the 30 items were removed for violating monotonicity (6 items) and exceeding Rasch infit (2 items). The rating scale was collapsed from 5 to 3 ratings because of structure issues. The remaining 22 MPAI-4 items demonstrated excellent item/person reliability (0.98/0.91) and separated person ability into 4 strata. Two of the MPAI-4 index scores (abilities and adjustment) had good measurement properties. The third index, M2PI, retained only 3 items that had adequate person reliability (0.75) but separated person ability into only 2 strata. A significant but fair association with the CIQ was demonstrated with the modified MPAI-4. CONCLUSIONS: The MPAI-4 has been validated in moderate to severe traumatic brain injury but required modification when used in active military personnel with mTBI. We also identified the need for modification of the MPAI-4 to support adequate psychometrics when measuring outcomes in veterans with mTBI. Additional validation of the M2PI is needed in veterans and active military personnel with mTBI, to determine whether the M2PI should continue to be used as an outcome measure in the VHA polytrauma rehabilitation systems.

An Investigation of Exposure Control Methods With Variable-Length CAT Using the Partial Credit Model.

The purpose of this simulation study was to investigate the effect of several different item exposure control procedures in computerized adaptive testing (CAT) with variable-length stopping rules using the partial credit model. Previous simulation studies on CAT exposure control methods with polytomous items rarely considered variable-length tests. The four exposure control techniques examined were the randomesque with a group of three items, randomesque with a group of six items, progressive-restricted standard error (PR-SE), and no exposure control. The two variable-length stopping rules included were the SE and predicted standard error reduction (PSER), along with three item pools of varied sizes (43, 86, and 172 items). Descriptive statistics on number of nonconvergent cases, measurement precision, testing burden, item overlap, item exposure, and pool utilization were calculated. Results revealed that the PSER stopping rule administered fewer items on average while maintaining measurement precision similar to the SE stopping rule across the different item pool sizes and exposure controls. The PR-SE exposure control procedure surpassed the randomesque methods by further reducing test overlap, maintaining maximum exposure rates at the target rate or lower, and utilizing all items from the pool with a minimal increase in number of items administered and nonconvergent cases.

Adaptation to repeated gait-slip perturbations among individuals with multiple sclerosis.

BACKGROUND: Perturbation training, built upon motor adaptation and learning, has been increasingly used as a fall prevention paradigm in older adults. This training paradigm involves repeated externally-induced perturbations (like slips) to facilitate the error-driven learning of necessary motor skills for preventing falls. It remains unknown if people with multiple sclerosis can adapt to large-scale slip perturbations, which impedes the application of perturbation training in persons with multiple sclerosis. This study explored whether people with multiple sclerosis can adapt to large-scale repeated gait-slips. METHODS: Thirteen individuals with multiple sclerosis (the mean ± standard deviation of the Patient Determined Disability Steps: 2.27 ± 1.42) were exposed unexpectedly to a block of five repeated standard slips while walking on a treadmill. The outcome (fall or recovery) for each slip, as our primary outcome measure, was determined. A battery of secondary variables, including dynamic gait stability and gait parameters, were also calculated. Both primary and secondary variables were compared across trials. RESULTS: Our participants showed a rapidly reduced slip-fall rate (from 92.3% on the first slip to 30.8% on the fifth, p < 0.001). They mainly adopted proactive, assisted by reactive, strategies to improve dynamic gait stability, thus reducing the risk of slip-falls. The proactive adjustments, including shortened step, reduced foot landing angle, and flexed knee, shifted the center of mass anteriorly to be closer to the base of support. Such changes in center of mass position improved dynamic gait stability before the slip. Dynamic gait stability after the slip was also improved across trials, as a reactive strategy. CONCLUSION: With practice, people with multiple sclerosis can adapt to large-scale, high-speed, gait-slips and acquire necessary skills against falls. Such skills primarily involve proactive strategy which is assisted by reactive strategy. The proactive strategy would shift the body's center of mass closer to the base of support, improving dynamic gait stability and reducing falls. Our findings could provide a theoretical foundation for deploying perturbation training to prevent falls in people with multiple sclerosis.

Factor Structure of the Community Reintegration of Service-Members (CRIS) in Veterans with Blast-Related Mild Traumatic Brain Injury.

Veterans with blast-related mild traumatic brain injury (mTBI) report difficulty engaging in life roles, also referred to as participation. Current measures are either global or lack comprehensive coverage of life roles and have not been validated in Veterans with mTBI. The Community Reintegration of Service-members instrument (CRIS) is a promising measure that was specifically developed for Veterans using a well-formulated conceptual framework and Rasch analysis. However, the CRIS has not been validated in Veterans with mTBI. Two data sets were combined for 191 Veterans with blast-related mTBI to conduct a confirmatory factor analysis of the CRIS. High residual and low loading items (33) were removed to improve the model fit. The remaining items demonstrated high correlation (0.87-0.89) between subscales and high test re-test (0.85 to 0.95). Mean scores were better for Veterans without Post Traumatic Stress Disorder (PTSD) or depression compared to Veterans with PTSD or depression. The refined CRIS offers a valid comprehensive measure of participation for Veterans with blast-related mTBI. Future directions include examining aspects of participation that may not be covered by the CRIS for Veterans with mTBI..

Gender Differences in Psychosocial and Physical Outcomes in Haitian Amputees.

OBJECTIVE: The purpose of this study was to investigate the gender differences in psychosocial and physical outcomes in users of lower-extremity prostheses who became amputees after the 2010 earthquake in Haiti. METHOD: We enrolled 140 unilateral amputees in this cross-sectional study in Port-au-Prince, Haiti. Trained staff administered the assessments by reading the questions aloud to participants. Participants completed the Trinity Amputation and Prosthesis Experience Scales and Locomotor Capabilities Index about 2 yr after the earthquake. RESULTS: We found no gender differences in psychosocial adjustment and physical outcomes, except for strenuous physical activities and phantom pain, and both genders reported difficulty in social adjustment. After controlling for strenuous physical activities and phantom pain, we found that men showed worse psychosocial adjustment than women. CONCLUSION: Services for psychosocial adjustment are critical for traumatic amputees and should be incorporated into rehabilitation programs after a disaster. Interventions should consider gender roles in the indigenous culture.

Psychometric Properties of 2 Participation Measures in Veterans With Mild Traumatic Brain Injury.

OBJECTIVE: To compare the psychometric properties of 2 commonly used participation measures: the Community Reintegration of Service Members (CRIS) and the Participation Assessment with Recombined Tools-Objective (PART-O) in veterans with mild traumatic brain injury (mTBI). DESIGN: Data were collected from 2 cross-sectional observation studies conducted in 2 Veterans Affairs medical centers. SETTING: Questionnaires were completed in-person or by mail. PARTICIPANTS: Veterans with mTBI (N=201) were recruited from the Michael E. DeBakey Veterans Affairs Medical Center in Houston (n=94) and the Malcom Randall North Florida/South Georgia Veterans Health System (n=107). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: CRIS and PART-O. RESULTS: We conducted Rasch analysis on the PART-O and on 3 subscales of the CRIS (extent of participation, perceived limitation, and satisfaction). For PART-O, results showed PART-O has questionable unidimensionality. For both instruments, some rating categories were underused, and rating scales did not advance accordingly. Compared with PART-O, the CRIS was able to distinguish more categories of person's ability (>5 vs 2 for PART-O) and had better internal consistency as indicated by higher Cronbach α (.96-.98 vs .65 for PART-O). CONCLUSIONS: To capture participation unique to veterans with mTBI, CRIS has greater potential to detect a change in participation and is therefore recommended over PART-O. Rating scales of both instruments, however, need further refinement. We suggest future studies examine collapsed rating categories and use qualitative methods to redefine categories.

Functional and psychosocial status of Haitians who became users of lower extremity prostheses as a result of the 2010 earthquake.

The January 12, 2010 earthquake devastated Port-Au-Prince, the capital of the Republic of Haiti, and its surroundings. Among the 300,000 injured, 1,200 to 1,500 people underwent traumatic /surgical amputations. The purpose of this study was to describe the functional and psychosocial impact of prostheses users who suffered a traumatic lower-limb amputation after the earthquake of 2010 in Haiti. We recruited 140 participants in collaboration with a large health care organization in Port-au-Prince from October 2011 to May 2012. Participants underwent an evaluation of physical impairments and completed questionnaires translated into Haitian Creole. The Trinity Amputation and Prosthesis Experience Scale (TAPES), and the Locomotor Capabilities Index (LCI) were used in this study. The questionnaires were administered verbally in Haitian Creole by a trained staff. We conducted descriptive statistics and t-tests using SPSS for data analysis. Participants had a mean age of 34.9 ± 12.0; 51.4% were women; 48.6% were transfemoral amputees. The mean of TAPES general adjustment (3.65 ± 0.59) and adjust to limitation (3.67 ± 0.86) were higher than the score for the social adjustment (2.58 ± 0.49). The LCI showed over 90% of subjects were physically independent in self-care; fewer were independent walking on uneven ground or inclement weather (69%). The relatively poor social adjustment is consistent with the literature that describes limited acceptance of people with physical disabilities in Haitian society. Prostheses users in Haiti would benefit from a health delivery infrastructure that also addresses the psychosocial reintegration of individuals with physical disabilities.

The item level psychometrics of the behaviour rating inventory of executive function-adult (BRIEF-A) in a TBI sample.

PRIMARY OBJECTIVE: To determine whether the psychometrics of the BRIEF-A are adequate for individuals diagnosed with TBI. RESEARCH DESIGN: A prospective observational study in which the BRIEF-A was collected as part of a larger study. METHODS AND PROCEDURES: Informant ratings of the 75-item BRIEF-A on 89 individuals diagnosed with TBI were examined to determine items level psychometrics for each of the two BRIEF-A indexes: Behaviour Rating Index (BRI) and Metacognitive Index (MI). Patients were either outpatients or at least 1 year post-injury. MAIN OUTCOMES AND RESULTS: Each index measured a latent trait, separating individuals into five-to-six ability levels and demonstrated good reliability (0.94 and 0.96). Four items were identified that did not meet the infit criteria. CONCLUSIONS: The results provide support for the use of the BRIEF-A as a supplemental assessment of executive function in TBI populations. However, further validation is needed with other measures of executive function. Recommendations include use of the index scores over the Global Executive Composite score and use of the difficulty hierarchy for setting therapy goals.

Psychometrics of the self-report safe driving behavior measure for older adults.

We investigated the psychometric properties of the 68-item Safe Driving Behavior Measure (SDBM) with 80 older drivers, 80 caregivers, and 2 evaluators from two sites. Using Rasch analysis, we examined unidimensionality and local dependence; rating scale; item- and person-level psychometrics; and item hierarchy of older drivers, caregivers, and driving evaluators who had completed the SDBM. The evidence suggested the SDBM is unidimensional, but pairs of items showed local dependency. Across the three rater groups, the data showed good person (≥3.4) and item (≥3.6) separation as well as good person (≥.93) and item reliability (≥.92). Cronbach's α was ≥.96, and few items were misfitting. Some of the items did not follow the hypothesized order of item difficulty. The SDBM classified the older drivers into six ability levels, but to fully calibrate the instrument it must be refined in terms of its items (e.g., item exclusion) and then tested among participants of lesser ability.

Rater reliability and rater effects of the Safe Driving Behavior Measure.

We used Safe Driving Behavior Measure (SDBM) to determine rater reliability and rater effects (erratic responses, severity, leniency) in three rater groups: 80 older drivers (mean age = 73.26, standard deviation = 5.30), 80 family members or caregivers (age range = 20-85 yr), and two driving evaluators. Rater agreement was significant only between the evaluators and the family members or caregivers. Participants rated driving ability without erratic effects. We observed an overall rater effect only between the evaluator and family members or caregivers, with the evaluators being the more severe rater group. Training family members or caregivers to rate driving behaviors more consistently with the evaluator's ratings may enhance the SDBM's usability and provide a role for occupational therapists to interpret proxy reports as an entry point for logical and efficient driving safety interventions.

Using three legacy measures to develop a health-related quality of life tool for young adult survivors of childhood cancer.

BACKGROUND: Little attention has been paid to selecting and developing health-related quality of life (HRQOL) measurement tools for young adult survivors of childhood cancer (YASCC). The primary purpose of this study was to develop a HRQOL tool for YASCC based on three legacy instruments. METHODS: Data collected from 151 YASCC were analyzed. HRQOL was measured using the Medical Outcomes Study SF-36, Quality of Life in Adult Cancer Survivors, and Quality of Life-Cancer Survivor. We used the following stages to develop our HRQOL tool: mapping items from three instruments into a common HRQOL construct, checking dimensionality using confirmatory factor analyses (CFA), and equating items using Rasch modeling. RESULTS: We assigned 123 items to a HRQOL construct comprised of six generic and eight survivor-specific domains. CFA retained 107 items that meet the assumptions of unidimensionality and local independence. Rasch analysis retained 68 items that satisfied the indices of information-weighted/outlier-sensitive fit statistic mean square. However, items in most domains possess relatively easy measurement properties, whereas YASCC's underlying HRQOL was on the middle to higher levels. CONCLUSIONS: Psychometric properties of the established tool for measuring HRQOL of YASCC were not satisfied. Future studies need to refine this tool, especially adding more challenging items.