Community outcomes following traumatic brain injury: impact of race and preinjury status.

OBJECTIVE: To investigate the contribution of preinjury differences and potential biases in outcome measurement in explaining outcome differences between white and African American persons with moderate and severe traumatic brain injury (TBI). DESIGN: Prospective, 2 group longitudinal study with retrospective self-assessment of preinjury status. SETTING: Inpatient and outpatient TBI rehabilitation program. PARTICIPANTS: Ninety-four persons with moderate and severe TBI (55 whites and 39 African Americans) who provided data on both preinjury status and 1-year outcome. MEASURES: Community Integration Questionnaire, aggression and depression subscales of Neurobehavioral Functioning Inventory-Revised, Satisfaction With Life Scale, other questions on demographic and social status; all measures were selected by a biracial focus group. RESULTS: Whites and African Americans did not differ significantly on demographic factors except gender; nor on retrospective, self-reported preinjury status on any of the outcome measures. At 1 year post-TBI, African Americans reported significantly lower social integration subscale scores than whites. African Americans may also have lost more income than did whites. All other outcome measures were comparable between groups and showed declines in community productivity, increases in depression symptoms, and lower satisfaction with life for both whites and African Americans compared to preinjury. A higher rate of change in living situation post-TBI may partially account for lower levels of social integration for African Americans. CONCLUSION: Whites and African Americans who are comparable prior to injury may experience generally similar outcomes, but differences in social and financial outcomes require further investigation.

The relationship between neuropsychologic function and level of caregiver supervision at 1 year after traumatic brain injury.

OBJECTIVES: To evaluate distribution of levels of caregiver supervision at 1 year after traumatic brain injury, and to determine neuropsychologic predictors of supervision level. DESIGN: Prospective longitudinal design, concurrent measurement of neuropsychologic function and supervision level. SETTING: Seventeen Traumatic Brain Injury Model Systems centers. PARTICIPANTS: A total of 563 adults tested at 1 year postinjury; and a subgroup of 452 studied for neuropsychologic function in the absence of impairment in mobility or basic self-care, as assessed by high FIM instrument motor scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Supervision level measured by scores on Supervision Rating Scale (SRS). RESULTS: Two thirds (69%) of the sample was rated as independent of supervision. Participants without significant dysfunction on motor FIM were grouped into supervision groups differing in intensity of time commitment from caregiver (independent, moderate supervision, heavy supervision). In univariate analyses, groups differed on demographic variables (education, race, productivity prior to injury), duration of altered consciousness, and all but 1 neuropsychologic measure. A binomial regression model (complementary log-log model) revealed that supervision at 1 year was predicted by education and scores on the Trail Making Test Part B and digits backward. CONCLUSIONS: Findings confirm the importance of preinjury status and measures of working memory and cognitive flexibility in predicting functional independence after TBI. The SRS appears prone to ceiling effects in persons followed prospectively after moderate to severe TBI.

Characterization and correlates of medical and rehabilitation charges for traumatic brain injury during acute rehabilitation hospitalization.

OBJECTIVE: To identify factors associated with specific categories of charges during acute inpatient rehabilitation treatment after traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: A single Traumatic Brain Injury Model Systems (TBIMS) center. PARTICIPANTS: Eighty-four consecutive TBIMS patients. One exploratory analysis also included all 350 patients with TBI admitted during 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Average daily charges for specific categories of resource use (eg, room and board, rehabilitation therapies, functional labs). RESULTS: Room and board and rehabilitation therapy accounted for almost 90% of average daily charges. There was no linear component of change in average daily charges, but certain categories of charges were significantly higher during the first week than thereafter. Functional status at rehabilitation admission correlated with charges for respiratory, medical, and surgical supplies and with pharmacy and radiology, but not the other categories. Specific medical variables also correlated with specific charge categories. Focused chart reviews of patients with low and high charges in specific categories led to the formulation of additional predictive hypotheses. CONCLUSION: Certain categories of charges correlated with functional scores and acute medical variables that are known before admission to acute inpatient rehabilitation, allowing for better inpatient admission planning under prospective payment. Further research is needed to identify and correlate resource use that is bundled within the room and board category.

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity.

OBJECTIVE: To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity. DESIGN: Prospective observational design. SETTING: A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease. PARTICIPANTS: Twenty-one patients with spastic elbow flexion deformity. INTERVENTIONS: Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study. MAIN OUTCOME MEASURES: The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies. RESULTS: Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before. CONCLUSIONS: Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.

The impact of instrumented gait analysis on surgical planning: treatment of spastic equinovarus deformity of the foot and ankle.

BACKGROUND: Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision making is not well known. Our purpose in this study was to determine the influence of gait analysis with dynamic electromyography upon surgical planning in patients with upper motor neuron syndrome and gait dysfunction. METHODS: Two surgeons prospectively evaluated 36 consecutive adult patients with a spastic equinovarus deformity of the foot and ankle. After an initial history and physical exam, each surgeon independently formulated a surgical plan. Surgical treatment options for each individual muscle/tendon unit crossing the ankle included lengthening, transfer, release or no surgery. After the initial clinical evaluation and surgical planning, all patients then underwent instrumented gait analysis collecting kinetic, kinematic and poly-EMG data using a standard protocol by a single experienced physiatrist. Each surgeon reviewed the gait studies and patients independently and again formulated a surgical plan. The surgical plans were compared for each surgeon before and after gait study. The agreement between the two surgeon's surgical plans was also compared before and after gait study. Each patient was evaluated for the clinical outcome of surgery. RESULTS: Overall a change was made in 64% of the surgical plans after the gait study. The frequency of changing the surgical plan was not significantly different between the more and less experienced surgeons. The agreement between surgeons increased from 0.34 to 0.76 (p=0.009) after the gait study. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was seen in all patients that underwent surgical treatment. CONCLUSION: Instrumented gait analysis alters surgical planning for patients with equinovarus deformity of the foot and ankle and can produce higher agreement between surgeons in surgical planning. CLINICAL RELEVANCE: The equinovarus deformity is due to a variety of deforming forces and a single, best operation does not exist to correct all equinovarus deformities. Rather, a muscle specific approach that identifies the deforming forces will produce the best outcomes when treating the spastic equinovarus deformity.