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PURPOSE To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery. MATERIALS AND METHODS RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented. RESULTS Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p

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.

OBJECTIVE To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI). SETTING Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS). PARTICIPANTS A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations. DESIGN Secondary analysis from multicenter prospective longitudinal study. MAIN MEASURES Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale. RESULTS The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores. CONCLUSION Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Constraint-induced movement therapy (CI therapy) has been shown to reduce disability for individuals with upper extremity (UE) hemiparesis following different neurologic injuries. This article describes the study design and methodological considerations of the Bringing Rehabilitation to American Veterans Everywhere (BRAVE) Project, a randomized controlled trial of CI therapy to improve the motor deficit of participants with chronic and subacute traumatic brain injury. Our CI therapy protocol comprises 4 major components: (1) intensive training of the more-affected UE for target of 3 hour/day for 10 consecutive weekdays, (2) a behavioral technique termed shaping during training, (3) a "transfer package," 0.5 hour/day, of behavioral techniques to transfer therapeutic gains from the treatment setting to the life situation, and (4) prolonged restraint of use of the UE not being trained. The primary endpoint is posttreatment change on the Motor Activity Log, which assesses the use of the more-affected arm outside the laboratory in everyday life situations. Data from a number of secondary outcome measures are also being collected and can be categorized as physical, genomic, biologic, fitness, cognitive/behavioral, quality of life, and neuroimaging measures.

This chapter reviews the impact of brain injury on family caregivers and reviews what physiatrists can do to help family members.

Traumatic brain injury (TBI) is associated with a range of deficits that may negatively impact sexuality. Few studies have explored how professionals respond to sexuality issues among individuals with TBI. The present study aimed to examine the attitudes and level of training of international health professionals working with individuals with TBI and whether guidelines exist in their work settings related to sexual issues. A survey composed of 53 questions was developed to evaluate attitudes, professional training, and assessment related to sexuality among health professionals working with individuals with TBI. The sample consisted of 324 self-identified health care professionals. During their training, 83% of professionals reported not taking any specific courses, and 61% reported not taking any type of clinical practice related to sexuality issues after TBI. Approximately 70% reported knowing little information about sexuality issues related to TBI and believed it affected the way in which they address the topic with their patients. Professionals believed sexual expression among both cognitively intact (100%) and cognitively impaired (90%) patients was healthy. Sixty-nine percent reported their work setting had no guidelines to determine if an individual with TBI can consent to sexual activity or not. Sixty-six percent of professionals believed that a patient with severe TBI could consent to sexual activities; however 58% believed it is not their responsibility to determine that. Results demonstrated a need for enhanced educational curriculums with specific courses related to sexuality after TBI. Furthermore, institutions should develop guidelines for the assessment of capacity to consent to sexual activity.

Traumatic brain injury (TBI) is considered the signature injury of the Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (heretofore referred to as OEF/OIF/OND) US military conflicts. TBI can result in a myriad of cognitive, emotional, behavioral, and social-relational symptoms that can negatively influence one’s ability to parent. Additional factors can negatively impact the well-being of military families facing TBI, further increasing child-parent relationship strain: (1) high base rates of comorbid psychiatric conditions; (2) unique demographic characteristics of OEF/OIF/OND veterans; and (3) deployment stress that negatively impacts the emotional functioning of the veteran and their family. There remains a paucity of scientific literature supporting clinical interventions for improving parental functioning among veterans with TBI. With its focus on adaptive interactions and building a healthy child-parent bond, attachment theory offers a conceptual framework to consider when child-parent relationship ruptures occur after a parent has sustained a TBI.

To explore how health care professionals who work with individuals with TBI address issues related to the assessment and treatment of sexuality after TBI.A survey composed of 53 questions was developed to evaluate professional training, assessment of sexuality in individuals with TBI and attitudes towards sexuality. The sample consisted of 324 self-identified TBI health care professionals.Ninety seven per cent of participants believed that sexuality should be discussed during rehabilitation; however, 36% reported talking about it. Seventy nine per cent reported that their patients have asked about sexuality after TBI, with 60% feeling calm and competent addressing the topic. The main reason for not discussing the topic was that patients do not ask for information (42%). Assessment (87%) and treatment of sexuality (82%) in individuals with TBI are considered a part of their professional responsibility.Despite recognition of the importance of addressing the topic and the belief of it being their professional responsibility, many professionals reported lack of training. Working to increase comfort with the topic and providing comprehensive education on treating sexuality may be beneficial.

Objective To characterize supervision levels across residential settings at 1 year post-TBI and explore predictors of supervision in a Veteran and Service-member population. Setting Five VA Polytrauma Rehabilitation Centers. Participants A total of 302 individuals enrolled in the VA TBI Model Systems (TBIMS) research program. Design Prospective, longitudinal, multisite. Main measures Primary residence and supervision levels measured via scores on the Supervision Rating Scale. For predictive modeling, scores were dichotomized into 2 groups: those that were fully independent/living alone or required only some supervision during the day (independent group, n = 195) and those that required overnight supervision, full-time indirect supervision, and full-time direct supervision (dependent group, n = 107). Results Thirty-five percent were receiving supervision at 1 year post-TBI across residential settings and 28% were living in alternative settings. Multivariate modeling indicated that older age and longer posttraumatic amnesia (PTA) were predictive of having a need for supervision at 1 year postinjury. Conclusions Supervision needs are long-term features of moderate and severe TBI. Results of this study lend support to the shift toward conceptualizing TBI as a chronic disease.

OBJECTIVE To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma. SETTING Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs). PARTICIPANTS A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury. DESIGN Prospective, longitudinal, multisite. MAIN MEASURES Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment. RESULTS At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change. CONCLUSIONS The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

The purpose of this study was to analyze characteristics of individuals working in the profession of neuropsychology in Latin America in order to understand their background, professional training, current work situation, assessment and diagnostic procedures used, rehabilitation techniques employed, population targeted, teaching responsibilities, and research activities. A total of 808 professionals working in neuropsychology from 17 countries in Latin America completed an online survey between July 2013 and January 2014. The majority of participants were female and the mean age was 36.76 years (range 21-74 years). The majority of professionals working in neuropsychology in Latin America have a background in psychology, with some additional specialized training and supervised clinical practice. Over half work in private practice, universities, or private clinics and are quite satisfied with their work. Those who identify themselves as clinicians primarily work with individuals with learning problems, ADHD, mental retardation, TBI, dementia, and stroke. The majority respondents cite the top barrier in the use of neuropsychological instruments to be the lack of normative data for their countries. The top perceived barriers to the field include: lack of academic training programs, lack of clinical training opportunities, lack of willingness to collaborate between professionals, and lack of access to neuropsychological instruments. There is a need in Latin America to increase regulation, improve graduate curriculums, enhance existing clinical training, develop professional certification programs, validate existing neuropsychological tests, and create new, culturally-relevant instruments.

Background: There is a need to develop interventions that address the entire family after spinal cord injury (SCI), especially in Latin America, where rehabilitation resources are limited and little is known about family adjustment to SCI. Objective: To evaluate the short-term (post-intervention) and longer term (6-month) effectiveness of the newly developed, 8-session manualized family intervention for individuals with SCI and their family members compared to a control group. Methods: In this clinical demonstration project, longitudinal self-report data were collected from 8 individuals with SCI and their family members in Colombia, South America. The 8 families were randomly assigned to either the SCI intervention group or the waitlist control group. The intervention group included 10 individuals from 4 different families, with a mean age of 41.40 years (SD = 14.18). The control group was composed of 13 individuals from 4 different families with a mean age of 44.38 years (SD = 14.76). All participants completed Spanish versions of instruments that assessed depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden (Zarit Burden Interview), and perceived problem-solving skills (Problem-Solving Inventory). Results: Results provide preliminary evidence that symptoms of depression, anxiety, and burden as well as problem-solving appraisals improved significantly for individuals who participated in the intervention, whereas no change in symptoms was observed among those in the waitlist control group. Conclusions: Findings suggest that this newly developed intervention for families facing SCI can be beneficial; however, this pilot study represents only the first step in the examination of the efficacy and effectiveness of this intervention.

Objective To generate normative data on the Stroop Test across 11 countries in Latin America, with country-specific adjustments for gender, age, and education, where appropriate. Method The sample consisted of 3,977 healthy adults who were recruited from Argentina, Bolivia, Chile, Cuba, El Salvador, Guatemala, Honduras, Mexico, Paraguay, Peru, and, Puerto Rico. Each subject was administered the Stroop Test, as part of a larger neuropsychological battery. A standardized five-step statistical procedure was used to generate the norms. Results The final multiple linear regression models explained 14-36% of the variance in Stroop Word scores, 12-41% of the variance in the Stoop Color, 14-36% of the variance in the Stroop Word-Color scores, and 4-15% of variance in Stroop Interference scores. Although t-tests showed significant differences between men and women on the Stroop test, none of the countries had an effect size larger than 0.3. As a result, gender-adjusted norms were not generated. Conclusions This is the first normative multicenter study conducted in Latin America to create norms for the Stoop Test in a Spanish-Speaking sample. This study will therefore have important implications for the future of neuropsychology research and practice throughout the region.

Traumatic brain injury (TBI) is a signature injury among veterans who have served in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) combat operations, though this injury can also occur in the context of a number of other noncombat situations. This chapter presents a historical framework for the evolution in thinking about TBI, from conceptualizing it as a historical event to more modern conceptualizations of a chronic disease process. The chapter reviews ways to approach assessment and treatment of veterans with a history of concussion, with attention to the associations and symbolic significances that accompany a range of post-concussive symptoms, comorbid psychiatric symptoms, and the importance of involvement of the family system. Finally, the chapter discusses existing pathways of care for veterans with a history of TBI and future directions for research inquiry.

Objective To identify preinjury variables related to mental health treatment utilization at 2 years post-traumatic brain injury (TBI). Setting Veterans Affairs (VA) TBI Model Systems includes 5 VA Polytrauma Rehabilitation Centers. Participants Veterans and service members enrolled in TBI Model Systems who completed the year 2 follow-up assessment and provided mental health information. Sample was largely male (97%) and White (72%), with median age of 30 years. Design Participants with elevated mental health symptoms were identified by measures of depression, anxiety, and posttraumatic distress; suicide attempt in the past year; or problematic substance use in the past year. Forty-seven percent of participants had elevated mental health symptoms at 2 years postinjury. Among those with elevated symptoms, comparisons were made between those who sought mental health treatment in past year and those who did not. Main measures Demographic, historic, environmental, psychological/mental health, and injury/rehabilitation variables. Results Within the sample, 23% denied utilizing mental health services. Nonutilizers were more likely to deny a preinjury mental health treatment history, to report problematic substance use at year 2, and to report lower levels of internalizing symptoms than the treatment utilizers. Conclusion Veterans and service members with elevated mental health symptoms may require tailored tactics to promote treatment utilization post-TBI.

Objective Within the same time frame, compare the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and VA Traumatic Brain Injury Model System (TBIMS) data sets to inform future research and generalizability of findings across cohorts. Setting Inpatient comprehensive interdisciplinary rehabilitation facilities. Participants Civilians, Veterans, and active duty service members in the VA (n = 550) and NIDILRR civilian settings (n = 5270) who were enrolled in TBIMS between August 2009 and July 2015. Design Prospective, longitudinal, multisite study. Main measures Demographics, Injury Characteristics, Functional Independence Measures, Disability Rating Scale. Results VA and NIDILRR TBIMS participants differed on 76% of comparisons (18 Important, 8 Minor), with unique differences shown across traumatic brain injury etiology subgroups. The VA cohort was more educated, more likely to be employed at the time of injury, utilized mental health services premorbidly, and experienced greater traumatic brain injury severity. As expected, acute and rehabilitation lengths of stay were longer in the VA with no differences in death rate found between cohorts. Conclusions Substantial baseline differences between the NIDILRR and VA TBIMS participants warrant caution when comparing rehabilitation outcomes. A substantive number of NIDILRR enrollees had a history of military service (>13%) warranting further focused study. The TBIMS participant data collected across cohorts can be used to help evidence-informed policy for the civilian and military-related healthcare systems.

OBJECTIVE To identify predictors of satisfaction with life in Veterans 1 year after traumatic brain injury (TBI). SETTING The VA TBI Model Systems (TBIMS) project includes 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS Veterans enrolled in the VA TBIMS study who completed the Satisfaction With Life Scale at year 1 follow-up. The sample is largely male (96%) and Caucasian (72%), with a median age of 27 years upon enrollment. DESIGN Prospective observational cohort study measuring including demographics (eg, education), preinjury variables (eg, mental health history and employment), and military variables (eg, injury during deployment and injury during active duty status). MAIN OUTCOME MEASURE Satisfaction With Life Scale. RESULTS Multivariate regression analyses revealed that age, marital status, preinjury employment status, preinjury mental health history, and active duty status at the time of injury were significant predictors of life satisfaction at year 1 follow-up. CONCLUSIONS Results of this study suggest that satisfaction with life in Veterans with TBI is mediated by several factors that might inform rehabilitation interventions and discharge recommendations. Preinjury variables and active duty status (a unique aspect of the Veteran population) influence life satisfaction at 1 year postinjury. Limitations and future clinical implications will be discussed.

Objective The research attempting to disentangle the directionality of relationships between mental health and functional outcomes after traumatic brain injury (TBI) is growing but has yielded equivocal findings or focused on isolated predictors or isolated outcomes. The purpose of the current study was to use cross-lagged panel and structural equation modeling (SEM) techniques to examine causality between comprehensive indices of mental health (depression, anxiety, and life satisfaction) and functional independence in a national sample of individuals with TBI over the first 2 years after injury. Design Participants were 4,674 individuals with TBI from the TBI Model Systems Database. Results The SEM, which yielded good fit indices, suggested that individuals with TBI with greater mental health problems at 1 and 2 years after injury had lower functional independence at those same time points. The standardized path loadings for mental health problems and for functional independence over time were large, suggesting a high degree of consistency in mental health and functional independence across 1 and 2 years. In terms of cross-lag, mental health at Time 1 did not exert a unique effect on functional independence at Time 2, but functional independence at Time 1 exerted a statistically significant but quite small unique effect on mental health at Time 2. Conclusions This combination of results suggests that functional independence is only slightly more causal than mental health in the relationship between mental health and functional independence over the first 2 years post-TBI, and that instead, reciprocal causality is a more likely scenario. To claim cme credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) understand the nature of the relationship between mental health problems and functional independence after traumatic brain injury; (2) learn about a novel methodological technique for examining the connections between variables over time; and (3) understand when ongoing support for individuals with traumatic brain injury is necessary. Level Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.