Comparison of One-Year Postinjury Mobility Outcomes Between Locomotor Training and Usual Care After Motor Incomplete Spinal Cord Injury.

Objectives: To compare 1-year mobility outcomes of individuals with traumatic motor incomplete spinal cord injury (miSCI) who participated in standardized locomotor training (LT) within the first year of injury to those who did not. Methods: This retrospective case-control analysis conducted with six US rehabilitation hospitals used SCI Model Systems (SCIMS) data comparing 1-year postinjury outcomes between individuals with miSCI who participated in standardized LT to those who received usual care (UC). Participants were matched on age, gender, injury year, mode of mobility, and rehabilitation center. The primary outcome is the FIM Total Motor score. Other outcomes include the FIM Transfer Index, FIM Stairs, and self-reported independence with household mobility, community mobility, and stairs. Results: LT participants reported significantly better FIM Total Motor (difference = 2.812, 95% confidence interval [CI] = 5.896, 17.282) and FIM Transfer Index scores (difference = 0.958, 95% CI = 0.993, 4.866). No significant between-group differences were found for FIM Stairs (difference = 0.713, 95% CI = -0.104, 1.530) or self-reported household mobility (odds ratio [OR] = 5.065, CI = 1.435, 17.884), community mobility (OR = 2.933, 95% CI = 0.868, 9.910), and stairs (OR = 5.817, 95% CI = 1.424, 23.756) after controlling for multiple comparisons. Conclusion: LT participants reported significantly greater improvements in primary and secondary measures of mobility and independence (FIM Total Motor score; FIM Transfer Index) compared to UC participants. Self-reported mobility outcomes were not significant between groups.

The Interaction of Opiate Misuse and Marijuana Use on Behavioral Health Outcomes Using the Traumatic Brain Injury Model Systems Pain Collaborative Dataset.

OBJECTIVE: To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes. SETTING: Community. PARTICIPANTS: Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information. DESIGN: Cross-sectional, secondary analysis from a multisite observational cohort. MAIN OUTCOME MEASURES: Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality. RESULTS: Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated. CONCLUSIONS: Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association.

Characterization and Treatment of Chronic Pain After Traumatic Brain Injury-Comparison of Characteristics Between Individuals With Current Pain, Past Pain, and No Pain: A NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain. SETTING: Community. PARTICIPANTS: A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up. DESIGN: A multisite, cross-sectional observational cohort study. MAIN OUTCOME MEASURES: Functional outcomes, pain experience, and treatment. RESULTS: 46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size. CONCLUSIONS: Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment.

Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain. SETTING: Community. PARTICIPANTS: Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury. DESIGN: Multisite, cross-sectional observational cohort study. MAIN OUTCOME MEASURES: Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation). RESULTS: Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06). CONCLUSIONS: Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes.

Relationship Between Extreme Pain Phenotypes and Psychosocial Outcomes in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To examine the relationship between extreme pain phenotypes (interference and improvement) and psychosocial outcomes among those with chronic pain after traumatic brain injury (TBI). SETTING: Community. PARTICIPANTS: In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain. DESIGN: Multisite, cross-sectional, observational cohort study. PRIMARY MEASURES: Life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation, the Brief Pain Inventory (BPI) interference scale, and the Patient's Global Impression of Change (PGIC). RESULTS: Persons in the extreme high interference phenotype (vs extreme low interference phenotype) and/or extreme no change phenotype (vs extreme improvement phenotype) had poorer psychosocial outcomes, with extreme pain interference phenotypes having a larger effect on outcomes than extreme perceived improvement phenotypes. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptoms (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality. CONCLUSIONS: Examination of extreme phenotypes provides important insights into the experience of individuals living with chronic pain and TBI. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI.

Characterizing Extreme Phenotypes for Pain Interference in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To define and characterize extreme phenotypes based on pain interference for persons with chronic pain following traumatic brain injury (TBI). SETTING: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. PARTICIPANTS: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. PRIMARY MEASURES: The Brief Pain Inventory (BPI) interference scale, sociodemographic, injury, functional outcome, pain, and treatment characteristics. RESULTS: Participants were predominantly male (73%), White (75%), middle-aged (mean 46 years), and who were injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25th percentiles to create low-interference ( n = 441) and high-interference ( n = 431) extreme phenotypes. Bivariate comparisons found several sociodemographic, injury, function, pain, and treatment differences between extreme phenotype groups, including significant differences ( P < .001) on all measures of concurrent function with those in the low-interference extreme phenotype experiencing better function than those in the high-interference extreme phenotype. Lasso regression combined with logistic regression identified multivariable predictors of low- versus high-interference extreme phenotypes. Reductions in the odds of low- versus high-interference phenotypes were significantly associated with higher pain intensity (odds ratio [OR] = 0.33), having neuropathic pain (OR = 0.40), migraine headache (OR = 0.41), leg/feet pain (OR = 0.34), or hip pain (OR = 0.46), and more pain catastrophizing (OR = 0.81). CONCLUSION: Results suggest that for those who experience current chronic pain, there is high variability in the experience and impact of pain. Future research is needed to better understand how pain experience impacts individuals with chronic pain and TBI given that pain characteristics were the primary distinguishing factors between phenotypes. The use of extreme phenotypes for pain interference may be useful to better stratify samples to determine efficacy of pain treatment for individuals with TBI.

Characterizing Extreme Phenotypes for Perceived Improvement From Treatment in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To define and characterize extreme phenotypes based on perceived improvement in pain for persons with chronic pain following traumatic brain injury (TBI). SETTING: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. PARTICIPANTS: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. PRIMARY MEASURES: The Patient's Global Impression of Change (PGIC) related to pain treatment. Sociodemographic, injury, functional outcome, pain, and pain treatment characteristics. RESULTS: Participants were mostly male (73%), White (75%), middle-aged (mean 46 years), injured in motor vehicle accidents (53%), or falls (20%). Extreme phenotypes were created for an extreme improvement phenotype ( n = 512, 29.8%) defined as "moderately better" or above on the PGIC and an extreme no-change group ( n = 290, 16.9%) defined as no change or worse. Least absolute shrinkage and selection operator (LASSO) regression combined with logistic regression identified multivariable predictors of improvement versus no-change extreme phenotypes. Higher odds of extreme improvement phenotype were significantly associated with being female (odds ratio [OR] = 1.85), married versus single (OR = 2.02), better motor function (OR = 1.03), lower pain intensity (OR = 0.78), and less frequent pain, especially chest pain (OR = 0.36). Several pain treatments were associated with higher odds of being in the extreme improvement versus no-change phenotypes including pain medication (OR = 1.85), physical therapy (OR = 1.51), yoga (OR = 1.61), home exercise program (OR = 1.07), and massage (OR = 1.69). CONCLUSION: Investigation of extreme phenotypes based on perceived improvement with pain treatment highlights the ability to identify characteristics of individuals based on pain treatment responsiveness. A better understanding of the biopsychosocial characteristics of those who respond and do not respond to pain treatments received may help inform better surveillance, monitoring, and treatment. With further research, the identification of risk factors (such as pain intensity and frequency) for treatment response/nonresponse may provide indicators to prompt changes in care for individuals with chronic pain after TBI.

Suicide Attempts and Ideation Among Veterans/Service Members and Non-Veterans Over 5 Years Following Traumatic Brain Injury: A Combined NIDILRR and VA TBI Model Systems Study.

OBJECTIVE: This study compared rates of suicide attempt (SA) and suicidal ideation (SI) during the first 5 years after traumatic brain injury (TBI) among veterans and service members (V/SMs) in the Veterans Affairs (VA) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Model Systems National Databases to each other and to non-veterans (non-Vs) in the NIDILRR database. SETTING: Twenty-one NIDILRR and 5 VA TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States. PARTICIPANTS: Participants with TBI were discharged from rehabilitation alive, had a known military status recorded (either non-V or history of military service), and successful 1-, 2-, and/or 5-year follow-up interviews completed between 2009 and 2021. The year 1 cohort included 8737 unique participants (8347 with SA data and 3987 with SI data); the year 2 (7628 participants) and year 5 (4837 participants) cohorts both had similar demographic characteristics to the year 1 cohort. DESIGN: Longitudinal design with data collected across TBIMS centers at 1, 2, and 5 years post-injury. MAIN OUTCOMES AND MEASURES: History of SA in past year and SI in past 2 weeks assessed by the Patient Health Questionnaire-9 (PHQ-9). Patient demographics, injury characteristics, and rehabilitation outcomes were also assessed. RESULTS: Full sample rates of SA were 1.9%, 1.5%, and 1.6%, and rates of SI were 9.6%, 10.1%, and 8.7% (respectively at years 1, 2, and 5). There were significant differences among groups based on demographic, injury-related, mental/behavioral health, and functional outcome variables. Characteristics predicting SA/SI related to mental health history, substance use, younger age, lower functional independence, and greater levels of disability. CONCLUSIONS: Compared with participants with TBI in the NIDILRR system, higher rates of SI among V/SMs with TBI in the VA system appear associated with risk factors observed within this group, including mental/behavioral health characteristics and overall levels of disability.

Determining the Minimally Clinically Important Difference for the Disability Rating Scale in Persons With Chronic Traumatic Brain Injury.

The Extended Glasgow Outcome Scale (GOSE) is accepted as the primary outcome measure in registrational studies for traumatic brain injury (TBI). The Disability Rating Scale (DRS) is used to assess functional progress from initial acute injury, through rehabilitation and reintegration into the community and life. For these reasons, the DRS is an alternative measure for assessing meaningful global outcomes in chronic TBI. The objective of this study was to determine the minimally clinically important difference (MCID) for the DRS in chronic TBI, by determining the magnitude of DRS change associated with the MCID for the GOSE of 1 point. This study is a retrospective analysis of the multi-center, prospective, longitudinal, Traumatic Brain Injury Model Systems National Database of persons with outcomes at 1, 2, and 5 years and every 5 years thereafter post-injury. Spearman's correlations for dynamic and static relationships between the DRS and GOSE were significant. For the 1-point MCID for the GOSE, the dynamic MCID estimate for the DRS of a -0.68-point change was calculated as the mean DRS change associated with the difference of the GOSE score between year 1 and year 2 (score range, 3-8), using all persons in the study (n = 11,102), whereas the exploratory static MCID estimate for the DRS of -1.28 points was calculated from the slope of the best-fit line between the DRS and GOSE at year 1 follow-up (score range, 3-8; n = 13,415). The final MCID for the DRS was calculated by using the triangulation method (i.e., the arithmetic mean of the dynamic and exploratory static MCID estimates), which resulted in a -1.0-point change. The significant correlation between the DRS and GOSE has allowed for the establishment of a -1.0-point MCID for the DRS, which supports the use of the DRS as an alternative primary outcome measure for chronic TBI research studies, including clinical trials.

Traumatic brain injury as a chronic disease: insights from the United States Traumatic Brain Injury Model Systems Research Program.

Traumatic brain injury (TBI) is a global health priority, associated with substantial burden. Historically conceptualised as an injury event with finite recovery, TBI is now recognised as a chronic condition that can affect multiple domains of health and function, some of which might deteriorate over time. Many people who have had a TBI remain moderately to severely disabled at 5 years, are rehospitalised up to 10 years post-injury, and have a reduced lifespan relative to the general population. Understanding TBI as a chronic disease process can be highly informative for optimising care, which has traditionally focused on acute care. Chronic brain injury care models must be informed by a holistic understanding of long-term outcomes and the factors that can affect how care needs evolve over time. The United States Traumatic Brain Injury Model Systems of Care follows up individuals with moderate-to-severe TBI for over 30 years, allowing characterisation of the chronic (2-30 years or more post injury) functional, cognitive, behavioural, and social sequelae experienced by individuals who have had a moderate-to-severe TBI and the implications for their health and quality of life. Older age, social determinants of health, and lower acute functional status are associated with post-recovery deterioration, while younger age and greater functional independence are associated with risky health behaviours, including substance misuse and re-injury. Systematically collected data on long-term outcomes across multiple domains of health and function are needed worldwide to inform the development of models for chronic disease management, including the proactive surveillance of commonly experienced health and functional challenges.

The Association Between Payer Source and Traumatic Brain Injury Rehabilitation Outcomes: A TBI Model Systems Study.

OBJECTIVE: To examine the relationship between payer source for acute rehabilitation, residential median household income (MHI), and outcomes at rehabilitation discharge after traumatic brain injury (TBI). SETTING: Acute inpatient rehabilitation facilities. PARTICIPANTS: In total, 8558 individuals enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who were admitted to inpatient rehabilitation between 2006 and 2019 and were younger than 64 years. DESIGN: Secondary data analysis from a multicenter longitudinal cohort study. MAIN MEASURES: Payer source was divided into 4 categories: uninsured, public insurance, private insurance, and workers' compensation/auto. Relationships between payer source with residential MHI, rehabilitation length of stay (RLOS), and the FIM Instrument at discharge were examined. Covariates included age, injury severity, FIM at admission, and a number of sociodemographic characteristics including minority status, preinjury limitations, education level, and employment status. RESULTS: Individuals with workers' compensation/auto or private insurance had longer RLOS than uninsured individuals or those with public insurance after controlling for demographics and injury characteristics. An adjusted model controlling for demographics and injury characteristics showed a significant main effect of payer source on FIM scores at discharge, with the highest scores noted among those with workers' compensation/auto insurance. The main effect of payer source on FIM at discharge became nonsignificant after RLOS was added to the model as a covariate, suggesting a mediating effect of RLOS. CONCLUSION: Payer source was associated with preinjury residential MHI and predicted RLOS. While prior studies have demonstrated the effect of payer source on long-term outcomes due to lack of inpatient rehabilitation or quality follow-up care, this study demonstrated that individuals with TBI who are uninsured or have public insurance may be at risk for poorer functional status at the point of rehabilitation discharge than those with private insurance, particularly compared with those with workers' compensation/auto insurance. This effect may be largely driven by having a shorter length of stay in acute rehabilitation.

A comparison of one year outcomes between standardized locomotor training and usual care after motor incomplete spinal cord injury: Community participation, quality of life and re-hospitalization.

CONTEXT/OBJECTIVE: Spinal cord injury (SCI) often results in a significant loss of mobility and independence coinciding with reports of decreased quality of life (QOL), community participation, and medical complications often requiring re-hospitalization. Locomotor training (LT), the repetition of stepping-like patterning has shown beneficial effects for improving walking ability after motor incomplete SCI, but the potential impact of LT on psychosocial outcomes has not been well-established. The purpose of this study was to evaluate one year QOL, community participation and re-hospitalization outcomes between individuals who participated in a standardized LT program and those who received usual care (UC). DESIGN/SETTING/PARTICIPANTS: A retrospective (nested case/control) analysis was completed using SCI Model Systems (SCIMS) data comparing one year post-injury outcomes between individuals with traumatic motor incomplete SCI who participated in standardized LT to those who received UC. OUTCOME MEASURES: Outcomes compared include the following: Satisfaction with Life Scale (SWLS™), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF™), and whether or not an individual was re-hospitalized during the first year of injury. RESULTS: Statistically significant improvements for the LT group were found in the following outcomes: SWLS (P = 0.019); and CHART subscales [mobility (P = <0.001)]; occupation (P = 0.028); with small to medium effects sizes. CONCLUSION: Individuals who completed a standardized LT intervention reported greater improvements in satisfaction with life, community participation, and fewer re-hospitalizations at one year post-injury in comparison to those who received UC. Future randomized controlled trials are needed to verify these findings.

Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness.

OBJECTIVE: To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. DESIGN: Retrospective cohort. SETTING: NIDILRR and VA TBI Model Systems (TBIMS) centers. PARTICIPANTS: 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). MAIN OUTCOME MEASURE: Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. RESULTS: VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types. CONCLUSIONS: This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial.

OBJECTIVE: To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI). PARTICIPANTS AND DESIGN: Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy. OUTCOME MEASURES: Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go. RESULTS: No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment. CONCLUSION: Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

Longitudinal Patterns of Alcohol Use Following Traumatic Brain Injury in an Active Duty and Young Veteran Military Sample: A VA TBI Model Systems Study.

OBJECTIVE: To describe alcohol use among younger military active duty service members and veterans (SMVs) in the first 5 years after traumatic brain injury (TBI) and examine whether differential alcohol use patterns emerge as a function of brain injury severity and active duty service at time of injury. SETTING: Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: In total, 265 SMVs enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) PRC national database. Participants sustained a TBI of any severity level; received inpatient care at a PRC within 1 year of injury; were younger than 40 years; and completed survey interviews or questionnaires regarding their pre- and postinjury alcohol use for at least 3 of 4 time points (preinjury, postinjury years 1, 2, and 5). MAIN MEASURES: Self-reported alcohol use, defined as amount of weekly consumption and endorsement of binge drinking. Participant information related to demographics, injury, TBI severity, active duty status, mental health treatment, and FIM (Functional Independence Measure) total scores was also obtained to examine impact of these as covariates in the analyses. RESULTS: Alcohol use generally increased following an initial period of reduced consumption for SVMs with moderate-to-severe TBI. Individuals with mild TBI showed an opposite trend, with an initial period of increased use, followed by a decline and return to baseline levels in the long term. However, alcohol use did not significantly differ over time within this subsample after adjusting for covariates. CONCLUSIONS: The current study identified longitudinal alcohol use among a young, military/veteran cohort with a history of TBI, an at-risk population for problematic alcohol use. Patterns of self-reported alcohol consumption suggest the time frame of 2 to 5 years postinjury may be a critical window of opportunity for further intervention to maintain lowered levels of alcohol use, particularly among SVMs with moderate-to-severe TBI.

Health and cognition among adults with and without Traumatic Brain Injury: A matched case-control study.

OBJECTIVES: To evaluate associations between traumatic brain injury (TBI) and presence of health conditions, and to compare associations of health and cognition between TBI cases and controls. METHODS: This matched case-control study used data from the TBI Model Systems National Database (TBI cases) and Midlife in the United States II and Refresher studies (controls).  248 TBI cases were age-, sex-, race-, and education-matched without replacement to three controls. Cases and controls were compared on prevalence of 18 self-reported conditions, self-rated health, composite scores from the Brief Test of Adult Cognition by Telephone. RESULTS: The following conditions were significantly more prevalent among TBI cases versus controls: anxiety/depression (OR = 3.12, 95% CI: 2.20, 4.43, p < .001), chronic sleeping problems (OR = 2.76, 95% CI: 1.86, 4.10, p < .001), headache/migraine (OR = 2.61, 95% CI: 1.50, 4.54, p = .0007), and stroke (OR = 6.42, 95% CI: 2.93, 14.10, p < .001). The relationship between self-rated health and cognition significantly varied by TBI (pinteraction = 0.002). CONCLUSION: Individuals with TBI have greater odds of selected neurobehavioral conditions compared to their demographically similar uninjured peers. Among persons with TBI there was a stronger association between poorer self-rated health and cognition than controls. TBI is increasingly conceptualized as a chronic disease; current findings suggest post-TBI health management requires cognitive supports.

Patterns of Functional Change Five to Ten Years after Moderate-Severe Traumatic Brain Injury.

This study aims to characterize the patterns of functional change experienced between 5 and 10 years after moderate-severe traumatic brain injury (TBI). The study included TBI Model Systems national database participants (N = 372) at six sites who experienced TBI, received inpatient rehabilitation, and were followed at 5 and 10 years post-TBI. Outcome measures included self- or proxy-reported Functional Independence Measure (FIMTM) structured interview at 5 and 10 years post-TBI and domain change indices (DCIs) at 10 years to assess subjective change over the previous 5 years. When all seven FIM and subjective DCI subscales were considered together, 69% reported improvement in at least one subscale and 41% reported decline in at least one subscale; 51% reported more domains improved than declined, and 20% reported more domains declined than improved. Age at injury, post-traumatic amnesia duration, FIM, and depression and anxiety at year 5 were associated with FIM change and DCI measures. Although most persons with moderate-severe TBI do not experience widespread change from year 5 to 10 on individual FIM subscales or perceived domain-specific subscales, the vast majority do report change in one or more domains, with more improvement than decline and more change in subjective DCI than in FIM. Clinicians and researchers should be alert to the possibility of both positive and deleterious changes many years after TBI.

Prevalence of Drinking Within Low-Risk Guidelines During the First 2 Years After Inpatient Rehabilitation for Moderate or Severe Traumatic Brain Injury.

ABSTRACT: The objective of this retrospective, longitudinal study was to investigate the prevalence of drinking within the recommended limits (i.e., low-risk drinking) after moderate/severe traumatic brain injury (TBI). Data were drawn from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems National Database, a longitudinal dataset closely representative of the US adult population requiring inpatient rehabilitation for TBI. The sample included 6348 adults with moderate or severe TBI (injured October 2006-May 2016) who received inpatient rehabilitation at a civilian TBI Model Systems center and completed the alcohol consumption items preinjury and 1 and 2 yrs postinjury. National Institute on Alcohol Abuse and Alcoholism guidelines define low-risk drinking as no more than 4 drinks per day for men or 3 drinks per day for women and no more than 14 drinks per week for men or no more than 7 drinks per week for women. Low-risk drinking was common both before and after TBI, with more than 30% drinking in the low-risk level preinjury and more than 25% at 1 and 2 yrs postinjury. Postinjury, most drinkers consumed alcohol in the low-risk level regardless of preinjury drinking level. Definitive research on the long-term outcomes of low-risk alcohol consumption after more severe TBI should be a high priority.

Primary Language and Participation Outcomes in Hispanics With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine the relationship between primary language and participation outcomes in English- and Spanish-speaking persons with complicated mild to severe traumatic brain injury (TBI) at 1 year post-injury. SETTING: Community following discharge from inpatient rehabilitation. PARTICIPANTS: A total of 998 Hispanic participants with outcomes available at year 1 follow-up; 492 (49%) indicated English as their primary language and 506 (51%) indicated Spanish as their primary language. DESIGN: Prospective, multicenter, cross-sectional, observational cohort study. MAIN MEASURES: Community participation at 1 year post-injury was assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out and About, Productivity, and Social Relations. RESULTS: Unadjusted group comparisons showed better participation outcomes for English versus Spanish speakers for all PART-O domains and for the Balanced Total score. After controlling for relevant covariates, English-speaking participants had significantly better PART-O Balanced Total scores and better scores on the Social Relations domain, although effect sizes were small. CONCLUSIONS: Hispanic persons with TBI whose primary language is Spanish may require greater assistance integrating socially back into their communities after TBI. However, potential cultural differences in value placed on various social activities must be considered. Potential cultural bias inherent in existing measures of participation should be investigated in future studies.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years). DESIGN: Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations. RESULTS: Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites. CONCLUSIONS: The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.