Trends in the Characteristics and Outcomes of Older Medicare Patients With Traumatic Brain Injury Treated in Inpatient Rehabilitation Facilities: 2013 to 2018.

OBJECTIVE: To describe the characteristics and outcomes of older (65+) Medicare beneficiaries with traumatic brain injury (TBI) treated in inpatient rehabilitation facilities between 2013 and 2018. DESIGN: Descriptive study using IRF Patient Assessment Instrument (IRF-PAI) data reporting trends of the sociodemographic and clinical characteristics and outcomes of inpatient rehabilitation facilities Medicare patients with TBI. SETTING: Inpatient rehabilitation facilities in the United States. PARTICIPANTS: 99,804 older Medicare fee-for-service and Medicare Advantage patients with TBI (N=99,804). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay, self-care, and mobility functional outcomes, discharge destination. RESULTS: The number of older Medicare beneficiaries with TBI treated in inpatient rehabilitation facilities increased from 14,657 in 2013 to 18,791 in 2018, an increase of 28.2%. In addition to this overall increase in patients, we also found the percentage of men increased slightly (52.9% to 54.8%), there was a higher percentage of patients with tier 3 comorbidities, there was a decrease in the variability of length of stay, there was slightly more self-care and mobility improvement and a slightly higher percentage of patients discharged to the community (67.8% in 2013 and 71.6% in 2018). Newer standardized data showed that prior to the injury, more than one-third used a walker and more than three-quarters had a history of recent falls. CONCLUSIONS: Between 2013 and 2018, the number of Medicare beneficiaries with TBI treated in IRFs increased by approximately 28%. The characteristics of IRF older patients with TBI changed between 2013 and 2018 toward a slightly higher proportion of men, more comorbidities, and a higher percentage being discharged home after inpatient rehabilitation.

A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After Spinal Cord Injury.

OBJECTIVE: To derive and validate a simple, accurate CPR to predict future independent walking ability after SCI at the bedside that does not rely on motor scores and is predictive for those initially classified in the middle of the SCI severity spectrum. DESIGN: Retrospective cohort study. Binary variables were derived, indicating degrees of sensation to evaluate predictive value of pinprick and light touch variables across dermatomes. The optimal single sensory modality and dermatome was used to derive our CPR, which was validated on an independent dataset. SETTING: Analysis of SCI Model Systems dataset. PARTICIPANTS: Individuals with traumatic SCI. The data of 3679 participants (N=3679) were included with 623 participants comprising the derivation dataset and 3056 comprising the validation dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported ability to walk both indoors and outdoors. RESULTS: Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately identified future independent walkers 1 year after SCI. Normal pinprick in both lateral heels provided good prognosis, any pinprick sensation in either lateral heel provided fair prognosis, and no sensation provided poor prognosis. This CPR performed satisfactorily in the middle SCI severity subgroup. CONCLUSIONS: In this large multi-site study, we derived and validated a simple, accurate CPR using only pinprick sensory testing at lateral heels that predicts future independent walking after SCI.

Longitudinal Investigation of Alexithymia as a Predictor of Empathy, Emotional Functioning, Resilience, and Life Satisfaction 2 Years After Brain Injury.

OBJECTIVE: To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years after injury. DESIGN: Multicenter, longitudinal cohort study. SETTING: Data were collected during year 1 and year 2 postinjury follow-up interviews across 4 TBI Model System centers. PARTICIPANTS: Persons with TBI (N=175; 134 men and 41 women) who had English fluency and were capable of providing self-reported data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist - Civilian, Satisfaction with Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire 9, suicidal ideation, and problematic substance use. RESULTS: Simple adjusted models demonstrated that after controlling for the specific outcome at year 1, Toronto Alexithymia Scale-20 scores significantly predicted year 2 scores for perspective-taking, physical aggression, emotional dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning. CONCLUSIONS: Compared with those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1 year after injury reported poorer emotional health at 2 years after TBI, even after controlling for year 1 outcome scores, sociodemographic characteristics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process.

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.

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.

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.

Predictive modeling of ambulatory outcomes after spinal cord injury using machine learning.

STUDY DESIGN: Retrospective multi-site cohort study. OBJECTIVES: To develop an accurate machine learning predictive model using predictor variables from the acute rehabilitation period to determine ambulatory status in spinal cord injury (SCI) one year post injury. SETTING: Model SCI System (SCIMS) database between January 2000 and May 2019. METHODS: Retrospective cohort study using data that were previously collected as part of the SCI Model System (SCIMS) database. A total of 4523 patients were analyzed comparing traditional models (van Middendorp and Hicks) compared to machine learning algorithms including Elastic Net Penalized Logistic Regression (ENPLR), Gradient Boosted Machine (GBM), and Artificial Neural Networks (ANN). RESULTS: Compared with GBM and ANN, ENPLR was determined to be the preferred model based on predictive accuracy metrics, calibration, and variable selection. The primary metric to judge discrimination was the area under the receiver operating characteristic curve (AUC). When compared to the van Middendorp all patients (0.916), ASIA A and D (0.951) and ASIA B and C (0.775) and Hicks all patients (0.89), ASIA A and D (0.934) and ASIA B and C (0.775), ENPLR demonstrated improved AUC for all patients (0.931), ASIA A and D (0.965) ASIA B and C (0.803). CONCLUSIONS: Utilizing artificial intelligence and machine learning methods are feasible for accurately classifying outcomes in SCI and may provide improved sensitivity in identifying which individuals are less likely to ambulate and may benefit from augmentative strategies, such as neuromodulation. Future directions should include the use of additional variables to further refine these models.

10-year variability in high and low life satisfaction trajectories post-traumatic brain injury: a TBI model systems study.

PURPOSE: To determine how life satisfaction changes across the first 10 years following traumatic brain injury (TBI). METHODS: Participants included 1,941 individuals from the TBI Model Systems database with life satisfaction data at 1-, 5-, and 10-years post-TBI. Based on Satisfaction With Life Scale scores, individuals were characterized as having one of the five 10-year life satisfaction trajectories: 'Stable High,' 'Stable Low,' 'Increased to High,' 'Decreased to Low,' and 'Unstable.' These were analyzed for group differences in demographics and psychosocial and functional outcomes. RESULTS: Sixty percent participants had 'Stable High' or 'Increasing to High' trajectories. Approximately 25% had "Stable Low' or 'Decreasing to Low' trajectories, and approximately 15% had unstable trajectories. Higher life satisfaction trajectories were associated with the best psychosocial and functional outcomes whereas lower trajectories were associated with the worst psychosocial and functional outcomes. Trajectories were indistinguishable based on demographics. CONCLUSION: Life satisfaction over the first 10 years following TBI is dynamic, with most individuals reporting high life satisfaction by 10 years post-TBI. Examination of psychosocial and functional factors related to life satisfaction trajectories may inform community-based intervention recommendations, resources, and supports to maximize long-term satisfaction with life.

Predicting Outdoor Walking 1 Year After Spinal Cord Injury: A Retrospective, Multisite External Validation Study.

BACKGROUND AND PURPOSE: Predicting future outdoor walking ability after spinal cord injury (SCI) is important, as this is associated with community engagement and social participation. A clinical prediction rule (CPR) was derived for predicting outdoor walking 1 year after SCI. While promising, this CPR has not been validated, which is necessary to establish its clinical value. The objective of this study was to externally validate the CPR using a multisite dataset. METHODS: This was a retrospective analysis of US SCI Model Systems data from 12 centers. L3 motor score, L5 motor score, and S1 sensory score were used as predictor variables. The dataset was split into testing and training datasets. The testing dataset was used as a holdout dataset to provide an unbiased estimate of prediction performance. The training dataset was used to determine the optimal CPR threshold through a "leave-one-site-out" cross-validation framework. The primary outcome was self-reported outdoor walking ability 1 year after SCI. RESULTS: A total of 3721 participants' data were included. Using the optimal CPR threshold (CPR ≥ 33 threshold value), we were able to predict outdoor walking 1 year with high cross-validated accuracy and prediction performance. For the entire dataset, area under receiver operator characteristic curve was 0.900 (95% confidence interval: 0.890-0.910; P < 0.0001). DISCUSSION AND CONCLUSIONS: The outdoor walking CPR has been externally validated. Future research should conduct a clinical outcomes and cost-benefit impact analysis for implementing this CPR. Our results support that clinicians may use this 3-variable CPR for prediction of future outdoor walking ability.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A411 ).

Manual Wheelchair Configuration in Unilateral Upper- and Lower-Extremity Propulsion: A Randomized Crossover Study to Assess Effects of Rear Wheel Axle Position and Frame Type.

OBJECTIVE: To evaluate independence and exertion when using a lightweight wheelchair in comparison with ultra-lightweight wheelchairs (rigid and folding) for individuals with brain injury using a hemipropulsion technique. DESIGN: Randomized cross-over. SETTING: Rehabilitation hospital. PARTICIPANTS: Individuals diagnosed with brain injury resulting in hemiplegia using a hemipropulsion technique to mobilize in a manual wheelchair for at least 4 hours per day were recruited for this study. INTERVENTIONS: Eighteen participants were randomly assigned to complete skills and endurance testing in 3 different wheelchair configurations over a 3-week period: lightweight wheelchair; ultra-lightweight folding wheelchair; and ultra-lightweight rigid wheelchair. MAIN OUTCOME MEASURES: The primary outcome in this study was the percentage capacity score from the modified Wheelchair Skills Test 4.1. Secondary outcomes included the Wheelchair Propulsion Test, 100-m Push Test, heart rate, and rate of perceived exertion. RESULTS: Significant differences were found in the Wheelchair Skills Test (total score, low rolling resistance score, and the goal attainment score) favoring the ultra-lightweight wheelchairs over the lightweight wheelchair (P=.002, .001, and .016, respectively). Time to complete the 100-m push test was significantly faster for the ultra-lightweight rigid frame in comparison with the lightweight frame (P=.001; 30.89 seconds faster). Significance differences were not seen with the Wheelchair Propulsion Test measures across any of the wheelchair frames. Heart rate change and of perceived exertion were significantly lower for the ultra-lightweight rigid group in comparison with the lightweight group (P=.006 and .013, respectively). CONCLUSIONS: These data suggest that using an ultra-light weight wheelchair may lead to improved ability to complete wheelchair skills needed for successful mobility and a decrease in the actual and perceived physiological burden associated with propulsion in comparison to a lightweight wheelchair. A rigid frame may also enable faster mobility in comparison to a folding frame when hemi-propelling.

Venous Thromboembolism: Exploring Incidence and Utility of Screening in Individuals With Brain Injury.

OBJECTIVE: To determine the incidence of VTE in the population with brain injuries (BIs) using ultrasonography, and to assess the risk of pulmonary embolism (PE) development and/or bleeding complications related to anticoagulation. DESIGN: Retrospective study. SETTING: Acute rehabilitation hospital. PARTICIPANTS: 238 individuals with moderate to severe BI who were routinely screened for VTE with ultrasonography on admission to rehabilitation (N=238). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Retrospective chart review was performed to identify individuals who were diagnosed with VTE at the following 3 time points: in acute care prior to admission to rehabilitation, at the time of admission diagnosed via screening examination, and after admission to rehabilitation. Additionally, risk factors for VTE, PE, and incidence of bleeding complications related to therapeutic anticoagulation were assessed. RESULTS: 123 deep vein thromboses (DVTs) were identified with 38.2% in acute care (n=47), 69.1% on admission to rehabilitation (n=85), and 7.3% during the course of rehabilitation stay (n=9). Risk factors for development of VTE included age at injury, body mass index, injury etiology, history of neurosurgical procedure, and surgery during inpatient rehabilitation. Of those who were placed on therapeutic anticoagulation due to admission diagnosis of VTE (n=50), 2% developed recurrent DVT and 2% had bleeding complications. There was zero incidence of PE. CONCLUSION: We demonstrated a high prevalence of VTEs identified on screening ultrasonography on admission to inpatient rehabilitation among individuals with moderate to severe BIs, and low complications related to anticoagulation. Given the findings of this study, prospective research in ultrasonography screening for VTE in moderate to severe BI is needed.

Early Factors Predictive of Extreme High and Low Life Satisfaction 10 Years Post-Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To identify demographic, injury-related, and 1-year postinjury clinical and functional predictors of high and low life satisfaction at 10 years after moderate to severe traumatic brain injury (TBI) using an extreme phenotyping approach. SETTING: Multicenter longitudinal database study. PARTICIPANTS: A total of 3040 people from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems database with life satisfaction data at 10 years post-TBI. DESIGN: Multicenter, cross-sectional, observational design. MAIN MEASURES: Satisfaction With Life Scale (outcome), Glasgow Coma Scale, Disability Rating Scale, Functional Independence Measure, Participation Assessment with Recombined Tools-Objective, Patient Health Questionnaire-9, and General Anxiety Disorder-7 (standardized predictors). RESULTS: Greater cognitive and motor independence, more frequent community participation, and less depressive symptoms 1 year post-moderate to severe TBI predicted extreme high life satisfaction 10 years later. Non-Hispanic White and Hispanic individuals were significantly more likely than Black individuals to have extreme high life satisfaction 10 years post-TBI. CONCLUSIONS: Extreme phenotyping analysis complements existing knowledge regarding life satisfaction post-moderate to severe TBI. From a chronic disease management perspective, future studies are needed to examine the feasibility and impact of early postinjury medical and rehabilitative interventions targeting cognitive and motor function, community participation, and mood on the maintenance/enhancement of long-term life satisfaction post-TBI.

Factors Associated With High and Low Life Satisfaction 10 Years After Traumatic Brain Injury.

OBJECTIVE: To identify correlates of life satisfaction at 10 years after moderate to severe traumatic brain injury (TBI) using an extreme phenotyping approach. DESIGN: Effect sizes were calculated in this observational cohort study to estimate relationships of 10-year postinjury extremely high, extremely low, and moderate life satisfaction with (1) pre-injury demographics, injury-related factors, and functional characteristics at inpatient rehabilitation admission and discharge; and (2) postinjury demographics and clinical and functional measures at 10 years postinjury. SETTING: Multicenter longitudinal database study. PARTICIPANTS: People identified from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Database with life satisfaction data at 10 years post TBI (N=4800). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Satisfaction With Life Scale. RESULTS: Although few pre-injury factors or clinical and functional factors shortly after injury were associated with 10-year life satisfaction groups, the following 10-year postinjury factors were associated with extremely high vs extremely low life satisfaction group membership: greater independent functioning, less disability, more frequent community participation, being employed, and having fewer depressive and anxiety symptoms. Those with extremely high life satisfaction were distinctly different from those with moderate and extremely low satisfaction. Extremely high life satisfaction was underrepresented among non-Hispanic Black persons relative to non-Hispanic White persons. Relationships between life satisfaction and independent functioning, disability, and participation were attenuated among non-Hispanic Black persons. CONCLUSIONS: Extreme phenotyping analysis complements existing knowledge regarding life satisfaction after moderate to severe TBI and may inform acute and postacute clinical service delivery by comparing extremely high and extremely low life satisfaction subgroups. Findings suggest little association among personal, clinical, and functional characteristics early post TBI and life satisfaction 10 years later. Contemporaneous correlates of extremely high life satisfaction exist at 10 years post TBI, although the positive relationship of these variables to life satisfaction may be attenuated for non-Hispanic Black persons.

Enhancing Self-Advocacy After Traumatic Brain Injury: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the efficacy of a novel intervention aimed at enhancing self-advocacy in individuals living with traumatic brain injury (TBI). SETTING: Community. PARTICIPANTS: Sixty-seven (35 allocated to treatment, 32 to control) community-dwelling adults 9 months or more post-TBI (mean of 8.9 years postinjury); previously discharged from inpatient or outpatient TBI rehabilitation; able to travel independently in the community, indicating a level of independence needed to engage in self-advocacy. DESIGN: Longitudinal randomized 2-arm controlled trial (NCT no. 03385824). Computer-generated block randomization allocated participants to treatment/intervention or control/no-intervention. All outcome assessments completed by blinded study staff. INTERVENTION: A manualized group intervention, Self-Advocacy for Independent Life (SAIL), addressing the self-efficacy beliefs, knowledge, and skills for self-advocacy following TBI. MAIN OUTCOME MEASURES: The Self-Advocacy Scale (SAS) (primary); General Self-Efficacy Scale (GSE); Personal Advocacy Activity Scale (PAAS); Satisfaction With Life Scale (SWLS). RESULTS: The treatment group showed significantly greater improvement than controls from baseline to posttreatment on the primary measure (SAS) of self-efficacy specific to self-advocacy after TBI (effect size = 0.22). Similar improvements were found on secondary measures of general self-efficacy and satisfaction with life from baseline to posttreatment. However, significant between-groups gains for primary and secondary measures were not maintained over 6- and 12-week follow-up. CONCLUSIONS: Individuals living with chronic TBI sequelae can increase self-efficacy specific to self-advocacy, general self-efficacy, and satisfaction with life, through a TBI-specific intervention aimed at empowering individuals to advocate for their own needs and wishes. Sustaining gains over time may require ongoing community collaboration and support. This could involve community-based systems of self-advocacy education, resources, and peer support.

Association between weekly exercise minutes and resting IL-6 in adults with chronic spinal cord injury: findings from the fracture risk after spinal cord injury exercise study.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To assess associations between weekly aerobic exercise minutes and resting interleukin-6 (IL-6), C-reactive protein (CRP), or leptin levels in adults with chronic spinal cord injury (SCI). SETTING: Three hundred and forty-four community-dwelling men and women with SCI duration of > 1 year. METHODS: CRP, IL-6, and leptin levels were quantified by ultra-sensitive enzyme-linked immunoassay. Smoking, medication use, comorbidities, and aerobic exercise minutes per week were assessed by self-reported questionnaire. Body composition was determined by whole-body dual-energy X-ray absorptiometry. Generalized linear models were used to assess associations. RESULTS: In multivariable modeling, resting IL-6 levels were 0.001 pg/mL lower for every 1 min of weekly aerobic exercise. IL-6 levels increased with increasing android-to-gynoid fat ratio, in active/ever smokers compared to never smokers, and in individuals with skin pressure injuries compared to those without. IL-6 levels were lower in active ibuprofen users compared to nonusers. We found no association between weekly exercise minutes and CRP or leptin when designing similar models. CONCLUSIONS: Increasing aerobic exercise minutes is associated with lower IL-6 levels in adults with chronic SCI when considering body composition, smoking, skin pressure injuries, and ibuprofen use. CRP and leptin did not demonstrate an association with exercise when considering the similar variables. The use of these biomarkers in assessing the therapeutic value of future exercise-related interventions will be paramount for meaningful health improvement among those with SCI. Although a large, prospective dataset, this cross-sectional study cannot assign causation. Future prospective studies are needed to confirm these findings.

Marital Stability Over 10 Years Following Traumatic Brain Injury.

OBJECTIVE: To examine the stability of marriage from the time of traumatic brain injury (TBI) to 10 years postinjury. DESIGN: Retrospective cohort. SETTING: TBI Model Systems centers. PARTICIPANTS: In total, 1423 participants in the TBI Model Systems National Database who experienced TBI 10 years prior and were married at the time of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Remaining married to the same partner from the time of injury to 10-year follow-up. RESULTS: At 10 years, 66% (938) remained married to the same person. Significant associations were found with age at injury (P < .0001), sex (P = .0028), and preinjury problematic substance use (P = .0092). Marital stability over the 10-year period was higher for those who were older, were female, and had no problematic substance use history. Marital instability was greatest in the first year postinjury. CONCLUSIONS: Most married adults who received inpatient rehabilitation for TBI remained married to the same individual 10 years later. Those who were younger, were male, and had a history of problematic substance use were at a highest risk for relationship dissolution. Findings have implications for content, timing, and delivery of marital interventions. Substance use education and prevention appear to be important aspects of marital support.

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.

Predictors of Driving Status in Service Members and Veterans at 1 Year Posttraumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To identify predictors of driving status in service members and veterans 1 year following a traumatic brain injury (TBI). SETTING: The 5 Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: A total of 471 service members and veterans (128 with mild/complicated mild TBI and 343 with moderate/severe TBI) who received TBI-focused inpatient rehabilitation at one of the VA PRCs and who participated in a 1-year postinjury follow-up assessment. DESIGN: Secondary analysis from the Department of Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems (VA PRC TBIMS) national database. MAIN MEASURES: Primary outcome was a single item that assessed driving status at 1 year postinjury. Predictor variables included demographics; sensory impairment, substance use, and employment status at time of injury; PTSD symptoms reported at study enrollment; and functional impairment rated at rehabilitation discharge. RESULTS: In unadjusted bivariate analyses, among those with a mild/complicated mild TBI, older age and greater functional impairment were associated with lower likelihood of driving. Among those with a moderate/severe TBI, discharge to a nonprivate residence, greater functional impairment, and higher PTSD symptoms were linked to lower likelihood of driving. Adjusted multivariate analyses indicated that functional impairment was uniquely associated with driving status in both TBI severity groups. After controlling for other predictors, self-reported PTSD symptoms, particularly dysphoria symptoms, were associated with lower likelihood of driving in both severity groups. CONCLUSION: Given the significance of clinician-rated functional impairment and self-reported PTSD symptoms to the prediction of driving status 1 year post-TBI among service members and veterans, rehabilitation efforts to improve functioning and reduce negative affect may have a positive impact on driving and community integration.

Validation of the Injustice Experience Questionnaire (IEQ) in a spinal cord injury population.

STUDY DESIGN: Retrospective analysis of cross-sectional data. OBJECTIVES: To verify the factor structure of the Injustice Experience Questionnaire (IEQ) using a sample of individuals with spinal cord injury (SCI) and to assess IEQ scale reliability and construct validity using the same population. SETTING: Two SCI rehabilitation sites in the United States. METHODS: Three datasets were combined to conduct this validation study. The sample consisted of 341 adults with SCI who completed the IEQ, measures of psychological distress and pain, and provided sociodemographic and injury-related information. A series of confirmatory factor analyses (CFA) and exploratory factor analyses (EFA) were conducted to verify the two-factor structure of the IEQ, Cronbach's alpha was used to demonstrate scale reliability, and correlations between the IEQ and measures of pain and psychological distress were examined to assess construct validity. RESULTS: Poor model fit was observed for the two-factor structure of the IEQ as well as for the subsequent factor-structures that were explored. The IEQ demonstrated strong scale reliability (α = 0.89) and correlations between the IEQ and measures of pain and psychological distress were in the expected direction, indicating good construct validity. CONCLUSIONS: In this preliminary validation study, we failed to confirm the two-factor structure of the IEQ in a population of individuals with SCI. Though good scale reliability and construct validity were observed, further study is needed to refine the IEQ for use in this population.