Association Between Participation and Satisfaction With Life Over Time in Older Adults With Traumatic Brain Injury: A TBI Model Systems Study.

OBJECTIVE: To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults. SETTING: Community. PARTICIPANTS: Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older. DESIGN: Secondary data analysis of a large multicenter database. MAIN MEASURES: Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS). RESULTS: SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups. CONCLUSIONS: These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important.

Predictors of Multidimensional Profiles of Participation After Traumatic Brain Injury: A TBI Model Systems Study.

OBJECTIVES: To identify personal, clinical, and environmental factors associated with 4 previously identified distinct multidimensional participation profiles of individuals following traumatic brain injury (TBI). SETTING: Community. PARTICIPANTS: Participants (n = 408) enrolled in the TBI Model Systems (TBIMS) Participation Module, all 1 year or more postinjury. DESIGN: Secondary data analysis of cross-sectional data from participants in a multicenter TBIMS module study on participation conducted between May 2006 and September 2007. Participants provided responses to questionnaires via a telephone interview at their study follow-up (1, 2, 5, 10, or 15 years postinjury). MAIN MEASURES: Participants provided responses to personal (eg, demographic), clinical (eg, function), environmental (eg, neighborhood type), and participation measures to create multidimensional participation profiles. Data from measures collected at the time of injury (preinjury questionnaire, injury characteristics) were also included. The primary outcome was assignment to one of 4 multidimensional participation profile groups based on participation frequency, importance, satisfaction, and enfranchisement. The measures used to develop the profiles were: Participation Assessment with Recombined Tools-Objective, Importance, and Satisfaction scores, each across 3 domains (Productivity, Social Relationships, Out and About in the Community) and the Enfranchisement Scale (contributing to one's community, feeling valued by the community, choice and control). RESULTS: Results of the multinomial regression analysis, with 4 distinct participation profile groups as the outcome, indicated that education, current employment, current illicit drug use, current driving status, community type, and Functional Independence Measure Cognitive at follow-up significantly distinguished participation profile groups. Findings suggest a trend toward differences in participation profile groups by race/Hispanic ethnicity. CONCLUSIONS: Understanding personal, clinical, and environmental factors associated with distinct participation outcome profiles following TBI may provide more personalized and nuanced guidance to inform rehabilitation intervention planning and/or ongoing clinical monitoring.

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.

Alternative Structure Models of the Traumatic Brain Injury Rehabilitation Needs Survey: A Veterans Affairs TBI Model Systems Study.

OBJECTIVE: To explore the factor structure of the Rehabilitation Needs Survey (RNS). DESIGN: Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI). SETTING: Five Inpatient Rehabilitation Facilities. PARTICIPANTS: Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378). MAIN OUTCOME MEASURE(S): RNS. RESULTS: RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40). CONCLUSIONS: The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination.

Identification of Factors in Moderate-Severe TBI Related to a Functional Decline in Cognition Decades After Injury.

OBJECTIVE: To investigate whether a functional decline in cognitive activities decades after moderate-to-severe traumatic brain injury (m-sTBI) might relate to injury features and/or lifetime health factors, some of which may emerge as consequences of the injury. DESIGN: Secondary analysis of the TBI Model Systems National Database, a prospective, multi-center, longitudinal study of patients with m-sTBI. SETTING: TBI Model Systems Centers. PARTICIPANTS: Included were 732 participants rated on the cognitive subscale of the Functional Independence Measure (FIM Cognitive), a metric for everyday cognitive skills, across 3 time points out to 20 years (visits at 2-, 10-, and 20-year follow-ups; N=732). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): FIM Cognitive Scale. Injury characteristics such as timing and features pertaining to severity and health-related factors (eg, alcohol use, socioeconomic status) were examined to discriminate stable from declining participants on the FIM Cognitive Scale using logistic regression. RESULTS: At 20 years post-injury, there was a low base rate of FIM Cognitive decline (11%, n=78), with most being stable or having meaningful improvement (89%, n=654). Older age at injury, longer duration of post-traumatic amnesia, and presence of repetitive seizures were significant predictors of FIM Cognitive decline in the final model (area under the curve=0.75), while multiple health-related factors that can represent independent co-morbidities or possible consequences of injury were not. CONCLUSION(S): The strongest contributors to reported functional decline in cognitive activities later-in-life were related to acute characteristics of m-sTBI and experiencing post-traumatic seizures. Future studies are needed integrating functional with performance-based cognitive assessments to affirm conclusions and identify the timeline and trajectory of cognitive decline.

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.

Predictors of High School and College Graduation After Sustaining a Moderate-to-Severe Traumatic Brain Injury.

OBJECTIVE: To identify early predictors of US high school and college graduation after moderate-to-severe traumatic brain injury (TBI). SETTING: Inpatient rehabilitation and community. PARTICIPANTS: TBI Model Systems participants, aged 16 to 24 years, enrolled as high school or college students at time of injury. DESIGN: Prospective cohort study. MAIN MEASURES: Successful graduation was defined as having a diploma (high school) or an associate/bachelor's degree (college) at 1-, 2-, or 5-year follow-up. Predictors were sex, race/ethnicity, urbanicity, preinjury substance abuse, primary rehabilitation payer, and functional independence at inpatient rehabilitation discharge. METHOD: We descriptively characterized differences between those who did and did not graduate high school and college within the first 5 years postinjury and identified early predictors of successful high school and college graduation using 2 binomial logistic regressions. RESULTS: Of those with known graduation status, 81.2% of high school and 41.8% of college students successfully graduated. Graduates in both groups were more often White than Black and had more functional independence at discharge. Among high school students, preinjury substance abuse was also a risk factor for not graduating, as was identifying as Hispanic or "other" race. CONCLUSIONS: Sociodemographic factors and disability influence graduation outcomes, requiring structural, institutional, and personal interventions for success.

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.

Family Needs After Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs. SETTING: Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI ( n = 427). DESIGN: Observational study. MAIN OUTCOME MEASURE: The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver. ANALYSES: Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains. RESULTS: FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs. CONCLUSIONS: The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-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.

Reinjury After Moderate to Severe TBI: Rates and Risk Factors in the NIDILRR Traumatic Brain Injury Model Systems.

OBJECTIVES: To compare characteristics of those who do and do not sustain subsequent traumatic brain injuries (TBIs) following index TBI and to identify reinjury risk factors. DESIGN: Secondary data analysis of an ongoing longitudinal cohort study. SETTING: TBI Model Systems Centers. PARTICIPANTS: In total, 11 353 individuals aged 16+ years. MAIN OUTCOME MEASURES: Ohio State University TBI Identification Method. RESULTS: In total, 7.9% of individuals reported sustaining a TBI post-index TBI. Twenty percent of reinjuries occurred within a year of the index TBI. Reinjury risk followed an approximate U-shaped distribution such that risk was higher in the first year, declined 2 to 10 years postinjury, and then increased after 10 years. A multivariable Weibull model identified predictors of reinjury: younger (<29 years) and middle-aged and older (50+ years) age at index TBI relative to middle age, pre-index TBI, pre-index alcohol and illicit drug use, incarceration history, and less severe index TBI. CONCLUSIONS: A subset of individuals who receive inpatient rehabilitation for TBI are at an increased risk for reinjury, and an injury-prone phenotype may be characterized by engagement in risk behaviors. Factors associated with reinjury risk may differ for younger versus middle-aged and older adults. Findings underscore the need for empirically informed risk stratification models to identify TBI survivors at risk for reinjury.

Cognitive-Communication Predictors of Employment Outcomes 1 and 5 Years Posttraumatic Brain Injury.

OBJECTIVE: To examine changes in functional memory, problem solving, comprehension, expression, and social communication over the first 2 years posttraumatic brain injury (TBI) and the ability of each to predict return to work (RTW) outcomes at 1 year and 5 years postinjury. DESIGN: Secondary analysis of data from a multicenter longitudinal cohort study. SETTING: Acute inpatient rehabilitation facilities and community follow-up. PARTICIPANTS: A total of 3543 individuals between 16 and 60 years of age who were competitively employed at the time of TBI and had completed year 1, year 2, and year 5 postinjury follow-ups. MAIN OUTCOME MEASURES: Year 1 and year 5 RTW status (± competitively employed) at the time of study completion. RESULTS: Greater function across each of the 5 cognitive-communication abilities was associated with RTW success at 1 year and 5 years post-TBI. At discharge, these 5 abilities showed comparable odds of predicting later employment. At year 1 and year 2 follow-ups, independence with problem solving was the most predictive of employment 5 years post-TBI, followed by social interaction, memory, expression, and comprehension. CONCLUSIONS: An increased rehabilitation focus on functional memory, problem solving, comprehension, expression, and social interaction post-TBI has the potential to improve RTW outcomes.

Refining understanding of life satisfaction in elderly persons with traumatic brain injury using age-defined cohorts: a TBI model systems study.

OBJECTIVE: Examine effects of age cohort on post-injury life satisfaction in elderly persons with TBIDesign: Retrospective cohortSetting: TBI Model Systems centers. PARTICIPANTS: 5,109 elderly participants with TBI in the TBI Model Systems National DatabaseInterventions: Not applicableMain Outcome Measures: Demographics, injury characteristics and cause, outcomes, age at time of analysis, time to follow commands, maximum follow-up period, and scores on the Satisfaction With Life Scale (SWLS) and Participation Assessment with Recombined Tools-Objective (PART-O) scores at 1, 2, 5, or 10 years post-injury. RESULTS: Life satisfaction post-TBI across groups increased with age. The young-old sub-group demonstrated the poorest life satisfaction outcomes, while the oldest sub-group experienced greatest life satisfaction. In contrast, participation decreased with age. CONCLUSIONS: Findings show diversity in satisfaction with life following moderate to severe TBI for three elderly age-cohorts. Differences may be due to variations in generation-based lived experience, in perceived meaningfulness of participation, could echo prior evidence of greater resilience in the oldest group, or could reflect bias within the study sample. Further research into between- and within- differences for elderly TBI age cohorts is needed to more precisely meet their needs for physical and functional rehabilitation as well as psychological supports.

Heterogeneity in Temporal Ordering of Depression and Participation After Traumatic Brain Injury.

OBJECTIVE: To examine heterogeneity in the temporal patterns of depression and participation over the first 2 years post traumatic brain injury (TBI). DESIGN: Observational prospective longitudinal study. SETTING: Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone. PARTICIPANTS: Persons with TBI (N=2307) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years post injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patient Health Questionnaire-9 (PHQ-9) and Participation Assessment With Recombined Tools-Objective (PART-O). RESULTS: Using latent class modeling we examined heterogeneity in the longitudinal relationship between PHQ-9 and PART-O. The identified 6 classes were most distinct in terms of (1) level of PHQ-9 score and (2) association between the year 1 PART-O score and year 2 PHQ-9 score. For most participants, PART-O at year 1 predicted PHQ-9 at year 2 more than the reverse. However, there was a subgroup of participants that demonstrated the reverse pattern, PHQ-9 predicting later PART-O, who were on average, older and in the "other" employment category. CONCLUSIONS: Results suggest that links between participation and depression are stronger for some people living with TBI than for others and that variation in the temporal sequencing of these 2 constructs is associated with demographic characteristics. These findings illustrate the value in accounting for population heterogeneity when evaluating temporal among outcome domains.

The Association Between Community Participation and Social Internet Use Among Adults With Traumatic Brain Injury.

OBJECTIVE: To examine the association between social Internet use and real-world societal participation in survivors of moderate-severe traumatic brain injury. DESIGN: Prospective cross-sectional observational study. SETTING: Ten Traumatic Brain Injury Model Systems Centers. PARTICIPANTS: A total of 331 participants in the Traumatic Brain Injury Model Systems, interviewed at any follow-up year between April 2014 and March 2015. MAIN MEASURES: Survey on Internet use, including social media and other online socialization; Participation Assessment with Recombined Tools-Objective with separate analyses of Productivity, Social Relations, Out and About subscales; covariates included demographics, injury variables, and functional and emotional status at follow-up. RESULTS: Participants were classified as social Internet users (N = 232) or nonusers (N = 99). Users had significantly higher Participation Assessment with Recombined Tools-Objective Social Relations scores than nonusers. A similar finding pertained to Out and About scores, with the between-group difference significantly greater for those with greater depressive symptoms severity. Users and nonusers did not differ significantly on Productivity subscale. CONCLUSIONS: The positive association between social Internet use and real-world social participation suggests that people with traumatic brain injury do not use social media as an alternative to real-world socialization. Rather, it is likely that similar barriers and facilitators affect both online and real-world social participation following traumatic brain injury. Emotional function should be considered as a moderating factor in further studies.

Influence of Prior and Intercurrent Brain Injury on 5-Year Outcome Trajectories After Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: To characterize the influence of additional (both prior and subsequent) traumatic brain injuries (TBIs) on recovery after a moderate to severe index TBI. SETTING: Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Persons with moderate to severe TBI (N = 5054) enrolled in the TBI Model Systems National Database with complete outcome data for the outcomes of interest at 1-, 2-, and 5-year follow-up. DESIGN: Secondary analysis of a prospective longitudinal data set. MAIN MEASURES: Prior and intercurrent TBI from the Ohio State University TBI Identification Method (OSU TBI-ID), Disability Rating Scale (DRS), and Functional Independence Measure (FIM). RESULTS: Prior moderate-severe TBIs significantly predicted overall level of functioning on the DRS, FIM Cognitive, and FIM Motor for participants with less severe index injuries. Moderate-severe intercurrent TBIs (TBIs subsequent to the index injury) were predictive of poorer functioning for both Index Severity groups, reflected in higher mean scores on the DRS in participants with less severe index injuries and lower mean Cognitive FIM in participants with more severe index injuries. CONCLUSION: Multiple brain injuries, particularly those of moderate or greater severity, have a significantly greater impact on patients' level of functioning compared with a single injury, but not the rate or shape of recovery.

Employment Stability in the First 5 Years After Moderate-to-Severe Traumatic Brain Injury.

OBJECTIVE: To characterize employment stability and identify predictive factors of employment stability in working-age individuals after moderate-to-severe traumatic brain injury (TBI) that may be clinically addressed. DESIGN: Longitudinal observational study of an inception cohort from the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) using data at years 1, 2, and 5 post-TBI. SETTING: Inpatient rehabilitation centers with telephone follow-up. PARTICIPANTS: Individuals enrolled in the TBIMS-NDB since 2001, aged 18-59, with employment data at 2 or more follow-up interviews at years 1, 2, and 5 (N=5683). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Employment stability, categorized using post-TBI employment data as no paid employment (53.25%), stably (27.20%), delayed (10.24%), or unstably (9.31%) employed. RESULTS: Multinomial regression analyses identified predictive factors of employment stability, including younger age, white race, less severe injuries, preinjury employment, higher annual earnings, male sex, higher education, transportation independence postinjury, and no anxiety or depression at 1 year post-TBI. CONCLUSIONS: Employment stability serves as an important measure of productivity post-TBI. Psychosocial, clinical, environmental, and demographic factors predict employment stability post-TBI. Notable predictors include transportation independence as well as the presence of anxiety and depression at year 1 post-TBI as potentially modifiable intervention targets.

Survivor-perceived motivational facilitators and barriers to participation in cognitive exercise following chronic acquired brain injury.

Primary objective: Motivation to initiate and persist with any kind of exercise activity is challenging. This pilot study queried adults with chronic-acquired brain injuries (ABI) regarding their perceptions about motivational facilitators of and barriers to engagement in cognitive exercise activity. Research design: A mixed methods design was used to characterize individuals' perceptions regarding exercise and their exercise experience (written questionnaire) and to obtain their input regarding exercise-related motivational strategies and obstacles (semi-structured group interviews). Methods: Thirty-four community-based individuals with chronic ABI and moderate-to-severe cognitive impairments completed questionnaires and engaged in audio-recorded scripted group interviews. Tallies of closed-ended questionnaire data and thematic analysis of open-ended questionnaire and group interview data were completed. Main outcomes and results: Participants indicated a strong preference for engaging in cognitive exercise activity with others versus alone. Frequently recurring motivational facilitators regarding exercise in general and cognitive exercise in particular included 'receipt of positive reinforcement for exercise activity', 'possession of needed information to engage in exercise', and 'possession of exercise-related goals'. Frequently recurring motivational barriers included 'absence of exercise-related goals' and 'absence of consistent structure conducive to exercise'. Conclusion: Study findings may facilitate successful engagement in cognitive exercise by chronic ABI survivors. Further research is needed.

Immediate memory and electrophysiologic effects of prefrontal cortex transcranial direct current stimulation on neurotypical individuals and individuals with chronic traumatic brain injury: a pilot study.

Purpose/aim: Memory impairment post-TBI is common, frequently persistent, and functionally debilitating. The purposes of this pilot study were to assess and to compare immediate behavioral auditory working memory and electrophysiologic effects of three different, randomized, conditions of left dorsolateral prefrontal cortex (LDLPFC) transcranial direct current stimulation (tDCS) applied to four neurotypical adults and four adults with chronic traumatic brain injury (TBI). MATERIALS/METHODS: Pre- and post-anodal, cathodal, and sham tDCS auditory memory performance, auditory event-related potentials (P300 amplitude and latency) and power of alpha and theta EEG bands were measured across individuals in each group. RESULTS: Post-anodal tDCS only, the neurotypical and TBI groups both demonstrated significantly improved immediate auditory memory function. Also post-anodal tDCS, the TBI group demonstrated significantly increased P300 amplitude versus post-sham tDCS. The neurotypical group demonstrated no pre- post-tDCS electrophysiologic changes across conditions. CONCLUSIONS: These findings are consistent with findings of other studies of immediate tDCS effects on other types of memory in neurotypical individuals and in individuals with Parkinson's disease, Alzheimer's disease and stroke and suggest that individuals with memory impairments second to chronic TBI may benefit from LDLPFC anodal tDCS. Pairing tDCS with traditional behavioral memory interventions may facilitate TBI rehabilitation outcomes and warrants continued investigation.

Feasibility and benefits of computerized cognitive exercise to adults with chronic moderate-to-severe cognitive impairments following an acquired brain injury: A pilot study.

PRIMARY OBJECTIVE: The purpose of this pilot study was to explore feasibility and effects of participation in a computerized cognitive fitness exercise program by a group of adults with chronic moderate-to-severe cognitive impairments following an acquired brain injury (ABI). RESEARCH DESIGN: This study used a mixed methods design with a convenience sample of individuals forming two groups (+/- exercise). METHODS AND PROCEDURES: Following neurocognitive and satisfaction with life pre-testing of 14 participants, seven were enrolled in a 5-month, 5-days a week computerized cognitive exercise program. Post-testing of all participants and semi-structured interviews of exercise group participants were completed. MAIN OUTCOMES AND RESULTS: It was feasible for adults with chronic moderate-to-severe cognitive impairments post-ABI to participate in a computerized cognitive exercise program with ongoing external cues to initiate exercise sessions and/or to complete them as needed. Significant exercise group improvements were made on memory and verbal fluency post-tests and life satisfaction. The majority of exercise group participants reported some degree of positive impact on cognitive abilities and some on everyday functioning from program participation. CONCLUSIONS: Adults with chronic moderate-to-severe cognitive impairments following an ABI may benefit from participation in computerized cognitive exercise programs. Further study is warranted.