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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., (Published by Elsevier Inc.)

Objective: To examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA)., Design: Multivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data., Setting: Five VA PRCs., Participants: VA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717)., Interventions: N/A., Main Outcome Measures: Total, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals., Results: A total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse., Conclusions: This study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings., (Published by Elsevier Inc.)

Objective: To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups., Design: Qualitative descriptive study guided by an access to health care services conceptual framework., Setting: Five Veterans Affairs (VA) polytrauma rehabilitation centers., Participants: SMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe)., Main Outcome Measures: Barriers and facilitators accessing care., Results: The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services., Conclusions: Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability., (Published by Elsevier Inc.)

Objective: To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI)., Design: Prospective observational cohort., Setting: Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers., Participants: VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y)., Interventions: Not applicable., Main Outcome Measures: Satisfaction With Life Scale (SWLS)., Results: Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction., Conclusions: Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To compare Veterans Health Administration (VHA) diagnoses, health services utilization, and costs by mild traumatic brain injury (mTBI) group (blast-related [BR] mTBI vs non-blast-related [NBR] mTBI vs no mTBI) among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans in the Chronic Effects of Neurotrauma Consortium multicenter observational study., Design: Prospective cohort study., Setting: Four Veterans Affairs Medical Centers., Participants: OEF/OIF/OND veterans (N=472) who used Veterans Affairs Medical Centers services between 2002-2017., Interventions: Not applicable. Lifetime mTBI history was assessed via semistructured interviews., Main Outcome Measures: VHA diagnoses, health services utilization, and costs., Results: Relative to NBR mTBI and no mTBI, veterans with BR mTBI were more likely to be male, have greater combat, and have controlled and uncontrolled detonations exposures (median BR, 15.0 vs NBR, 3.0 vs no mTBI, 3.0). They also had higher prevalence of headache, posttraumatic stress disorder, and anxiety diagnoses. Veterans with BR had the highest site-adjusted mean annual VHA utilization (26.31 visits; 95% confidence interval [CI], 26.01-26.61) relative to NBR (20.43 visits; 95% CI, 20.15-20.71) and no mTBI (16.62 visits; 95% CI, 16.21-17.04) and highest site adjusted mean annual VHA outpatient costs ($6480; 95% CI, $5842-$7187) relative to NBR ($4901; 95% CI, $4392-$5468) and no mTBI ($4069; 95% CI, $3404-$4864)., Conclusions: Veterans with BR mTBI had higher exposure to combat and detonation. BR was associated with greater prevalence of select diagnoses and higher health services utilization and costs relative to NBR and no mTBI. The role of health care needs from mTBI polytrauma, other deployment-related exposures, and VHA access warrants future research., (Published by Elsevier Inc.)

Objective: To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective., Design: A cost-benefit analysis of phased approaches to sleep apnea diagnosis., Setting: Six TBI Model System Inpatient Rehabilitation Centers., Participants: Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5)., Intervention: Not applicable., Main Outcome: Cost benefit., Results: At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness., Conclusions: The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA., (Published by Elsevier Inc.)

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions., Design: Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography., Setting: Six TBI Model System Inpatient Rehabilitation Centers., Participants: Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248., Intervention: Not applicable., Main Outcome Measures: Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47)., Results: The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, -0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples., Conclusion: This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the relationship between staff perceived irritability, anger, and aggression and posttraumatic stress disorder (PTSD) in veterans with traumatic brain injury (TBI) of all severity levels., Design: Longitudinal cohort design., Setting: Veterans Affairs Polytrauma Transitional Rehabilitation Programs., Participants: Veterans and service members with TBI of all severity levels enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers' Traumatic Brain Injury Model System national database (N=240)., Interventions: Not applicable., Main Outcome Measure: Univariable and multivariable logistic regression modeling was used to examine the association between irritability, anger, and aggression and potential risk factors, including PTSD symptoms. Irritability, anger, and aggression was measured as a single construct using an item from the Mayo-Portland Adaptability Inventory-4 that was rated by program staff at admission and discharge from the inpatient rehabilitation program. PTSD symptoms were assessed using the PTSD Checklist-Civilian Version., Results: PTSD symptoms uniquely predicted program staff-rated irritability, anger, and aggression at discharge even after controlling for severity of TBI, age, male sex, education, and annual earnings. The model explained 19% of the variance in irritability, anger, and aggression., Conclusions: When TBI severity and PTSD symptoms were considered simultaneously in a sample of veterans, only PTSD symptoms predicted staff-rated irritability, anger, and aggression. Given the negative outcomes linked with irritability, anger, and aggression, veterans may benefit from assessment and treatment of PTSD symptoms within rehabilitation settings., (Published by Elsevier Inc.)

Objective: To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition for the minimally conscious state (MCS) by reviewing the literature on the diagnosis, natural history, prognosis, and treatment of disorders of consciousness lasting at least 28 days., Methods: Articles were classified per the AAN evidence-based classification system. Evidence synthesis occurred through a modified Grading of Recommendations Assessment, Development and Evaluation process. Recommendations were based on evidence, related evidence, care principles, and inferences according to the AAN 2011 process manual, as amended., Results: No diagnostic assessment procedure had moderate or strong evidence for use. It is possible that a positive EMG response to command, EEG reactivity to sensory stimuli, laser-evoked potentials, and the Perturbational Complexity Index can distinguish MCS from vegetative state/unresponsive wakefulness syndrome (VS/UWS). The natural history of recovery from prolonged VS/UWS is better in traumatic than nontraumatic cases. MCS is generally associated with a better prognosis than VS (conclusions of low to moderate confidence in adult populations), and traumatic injury is generally associated with a better prognosis than nontraumatic injury (conclusions of low to moderate confidence in adult and pediatric populations). Findings concerning other prognostic features are stratified by etiology of injury (traumatic vs nontraumatic) and diagnosis (VS/UWS vs MCS) with low to moderate degrees of confidence. Therapeutic evidence is sparse. Amantadine probably hastens functional recovery in patients with MCS or VS/UWS secondary to severe traumatic brain injury over 4 weeks of treatment. Recommendations are presented separately., (Published by Elsevier Inc.)

Objective: To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC)., Methods: Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended., Recommendations: Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included., (Published by Elsevier Inc.)

Objectives: To present initial descriptive findings from the Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRC) Traumatic Brain Injury (TBI) Model Systems (MS) National Database., Design: Prospective cohort study., Setting: VA PRC TBIMS National Database., Participants: 712 service members and veterans with TBI who consented to participate between January 2010 and June 2015., Interventions: Not applicable., Main Outcome Measures: Demographics, preinjury characteristics, injury characteristics, rehabilitation course, functional outcomes, and discharge disposition by TBI severity level., Results: The study cohort was predominantly male with moderate to severe TBI secondary to vehicular accident or blast injury. Sixty-five percent were active duty service members; one-third had been injured during deployment. One-third reported mental health treatment and/or alcohol use problems in the year predating the index TBI. The median number of days between injury and PRC admission was 42.5. Nearly 25% reported clinical levels of posttraumatic stress disorder; 75% reported mild to moderate neurobehavioral symptomatology. The median length of stay in the PRC was 36 days; those with severe TBI had the longest lengths of stay. Functional independence ratings improved from admission to discharge across all TBI severity levels. A majority were discharged to urban areas to reside with spouses or other residents in private residences or adult homes, with some variability by injury severity., Conclusions: The VA PRC TBIMS national database is a rich source of information on a unique group of individuals with TBI and promises to complement existing knowledge on TBI in the civilian population., (Published by Elsevier Inc.)

Objective: To examine incidence and predictors of employment stability in veterans and military service members with traumatic brain injury (TBI) who return to work., Design: Prospective observational cohort study., Setting: Four rehabilitation centers., Participants: Veterans and military service members (N=110) with mild (26%), moderate (22%), or severe (52%) TBI enrolled in the Department of Veterans Affairs Polytrauma Rehabilitation Centers TBI Model Systems database within 2 years of injury who were discharged between January 2009 and June 2015., Interventions: Not applicable., Main Outcome Measure: Employment stability as reflected by competitive employment at 1- and/or 2-year follow-up., Results: Over half (n=61, 55%) of the participants had stable employment at the time the first competitive employment date was recorded. Individuals with stable employment were more likely to be white (79%) and to have slightly higher cognitive and motor discharge scores on the FIM. Based on univariate analysis, more severe TBI and higher FIM motor scores at discharge were significantly associated with employment stability. At follow-up, compared with veterans and military service members who had unstable employment, those with stable employment had higher scores on motor and cognitive FIM and lower scores of self-report symptoms on the Neurobehavioral Symptom Inventory, the 9-item Patient Health Questionnaire-Depression, the 7-item Generalized Anxiety Disorder Questionnaire, and the PTSD Checklist-Civilian version., Conclusions: A number of unique factors affect employment stability in veterans and military service members with TBI. Study findings identify veterans and military service members who have stable employment and predictors of employment stability., (Published by Elsevier Inc.)

Objective: To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission., Design: Retrospective study., Setting: Rehabilitation center., Participants: From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days., Interventions: None., Main Outcome Measures: Recovery of consciousness and the FIM instrument., Results: Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology., Conclusions: Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission., Design: Prospective observational study., Setting: Inpatient rehabilitation within TBIMS with annual follow-up., Participants: Of 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363)., Interventions: Not applicable., Main Outcome Measures: Participants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury., Results: The DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI., Conclusions: Although the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation., Design: Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research-funded Traumatic Brain Injury Model Systems (TBIMS)., Setting: Inpatient rehabilitation hospitals participating in the TBIMS program., Participants: Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36])., Interventions: Not applicable., Main Outcome Measures: FIM items., Results: For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years., Conclusions: Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Over the last decade, research on patients with disorders of consciousness (DOC) has suggested that their prognosis for functional recovery early after injury is surprisingly positive, particularly for those with traumatic etiologies; that meaningful recovery proceeds for longer intervals than previously appreciated; and that such individuals are often medically complex and challenging to manage. However, access to intensive specialty rehabilitation is limited for most individuals with DOC in the United States. The evolving understanding of DOC calls for a reconsideration of appropriate models of care. This collection of articles provides insight into the functional recovery of individuals with DOC, new tools for assessing prognosis, and the patterns of comorbidity that complicate the recovery process. In addition, models of care from the United States and Europe that attempt to address the needs of patients as well as their caregivers are presented., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To prospectively characterize the prevalence, course, and impact of acute sleep abnormality among traumatic brain injury (TBI) neurorehabilitation admissions., Design: Prospective observational study., Setting: Freestanding rehabilitation hospital., Participants: Primarily severe TBI (median emergency department Glasgow Coma Scale [GCS] score=7; N=205) patients who were mostly men (71%) and white (68%) were evaluated during acute neurorehabilitation., Interventions: None., Main Outcome Measure: Delirium Rating Scale-Revised-98 (DelRS-R98) was administered weekly throughout rehabilitation hospitalization. DelRS-R98 item 1 was used to classify severity of sleep-wake cycle disturbance (SWCD) as none, mild, moderate, or severe. SWCD ratings were analyzed both serially and at 1 month postinjury., Results: For the entire sample, 66% (mild to severe) had SWCD at 1 month postinjury. The course of the SWCD using a subset (n=152) revealed that 84% had SWCD on rehabilitation admission, with 63% having moderate to severe ratings (median, 24d postinjury). By the third serial exam (median, 35d postinjury), 59% remained with SWCD, and 28% had moderate to severe ratings. Using general linear modeling and adjusting for age, emergency department GCS score, and days postinjury, presence of moderate to severe SWCD at 1 month postinjury made significant contributions in predicting duration of posttraumatic amnesia (P<.01) and rehabilitation hospital length of stay (P<.01)., Conclusions: Results suggest that sleep abnormalities after TBI are prevalent and decrease over time. However, a high percent remained with SWCD throughout the course of rehabilitation intervention. Given the brevity of inpatient neurorehabilitation, future studies may explore targeting SWCD to improve early outcomes, such as cognitive functioning and economic impact, after TBI., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the contribution of caregiver emotional functioning and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury (TBI)., Design: Prospective cohort study., Setting: Three postacute comprehensive-integrated postacute rehabilitation programs associated with National Institute on Disability and Rehabilitation Research-funded TBI Model Systems Centers., Participants: Persons with medically documented TBI (N=136; 57% with severe TBI, 12% moderate, 31% mild), primarily men and 69% white., Interventions: Not applicable., Main Outcome Measures: Community Integration Questionnaire and Craig Handicap Assessment and Reporting Technique (CHART)., Results: After accounting for age, education, sex, and race/ethnicity, there was a significant interaction between caregiver emotional functioning and time since injury for CHART Occupation and Social Integration Scale scores. Better emotional functioning in caregivers was associated with greater occupation and social integration outcomes for persons who entered the postacute rehabilitation program within 6 months of injury, but not for those >6 months postinjury. There was no relationship of family functioning to participation outcomes, and no interaction between family functioning and time since injury., Conclusions: Caregiver distress should be accounted for in studies investigating the effectiveness of postacute rehabilitation after TBI. Screening of caregivers early during postacute rehabilitation can target those who need assistance to improve their support of the person with TBI., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation., Design: Observational prospective study with a 2-wave longitudinal component., Setting: Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone., Participants: Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury., Interventions: Not applicable., Main Outcome Measures: FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale., Results: Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI., Conclusions: Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI)., Design: Inception cohort., Setting: Three TBI Model Systems inpatient rehabilitation facilities., Participants: Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury., Interventions: Not applicable., Main Outcome Measures: Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique., Results: There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration., Conclusions: Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Sherer M, Yablon SA, Nakase-Richardson R. Patterns of recovery of posttraumatic confusional state in neurorehabilitation admissions after traumatic brain injury., Objective: To provide preliminary descriptions of patterns of resolution of symptoms of acute confusion after traumatic brain injury (TBI)., Design: Prospective, descriptive, cohort study., Setting: Inpatient neurorehabilitation unit., Participants: Patients (N=107) meeting criteria for posttraumatic confusional state at admission to inpatient rehabilitation., Interventions: Not applicable., Main Outcome Measure: Patterns of resolution of posttraumatic confusional state symptoms over the first 3 confusion assessment protocol evaluations for patients with mild, moderate, and severe confusion., Results: Posttraumatic confusional state symptoms resolving earliest were psychotic-type symptoms, decreased daytime arousal, and nighttime sleep disturbance. Fluctuation and cognitive impairment were the 2 most persistent symptoms. Seventy-three percent of patients showed improvement of 1 or more symptoms from the first to third evaluation. Confusion severity groups did not significantly differ on indices of injury severity (Glasgow Coma Scale score, time to follow commands) but did differ on functional status at discharge from inpatient rehabilitation., Conclusions: While posttraumatic confusional state is a heterogeneous disorder, there is a predictable pattern of symptom resolution. Differences in patients' confusion severity and patterns of symptoms may relate to differing underlying neural injury.

Objective: Early investigations classified traumatic brain injury (TBI) severity according to posttraumatic amnesia (PTA) duration, designating "greater than 7 days" as the most severe. PTA durations of more than 7 days are common in neurorehabilitation populations. Moreover, no study has derived a PTA severity schema anchored to late outcome. The purpose of this study was to develop a PTA severity classification schema., Design: Prospective observational study., Setting: Rehabilitation hospital., Participants: Sample included TBI Model System participants (N=280) with known or imputed PTA duration during acute hospitalization and 1-year productivity status. Participants were primarily male (70%), median age of 27 years; and the most common mechanism of injury was motor vehicle collisions (79%). For study purposes, 4 injury severity groups were identified by observing differences in productivity associated with different PTA durations., Interventions: None., Main Outcome Measure: Productivity status at 1 year postinjury., Results: Fisher exact test comparisons revealed significant differences among 3 of the groups. Most individuals with PTA fewer than 14 days had favorable 1-year outcome (68% productive), whereas worse outcomes were associated with PTA more than 28 days (18% productive)., Conclusions: If validated by other investigators, the proposed schema will be useful in determining prognosis for late functional status based on PTA duration.

Objectives: To determine (1) if more than 50% of patients with moderate to severe traumatic brain injury (TBI) who met study criteria can complete a battery of neuropsychologic tests in less than 75 minutes 2 to 6 weeks after injury regardless of posttraumatic amnesia (PTA) status; (2) which tests are most likely to be completed; and (3) range of scores obtained., Design: Prospective multicenter observational study., Setting: Acute inpatient neurorehabilitation hospitals., Participants: Screened 543 Traumatic Brain Injury Model System patients with moderate to severe TBI; 354 were tested at 2 to 6 weeks postinjury., Interventions: Not applicable., Main Outcome Measure: Percentage of patients able to complete the neuropsychologic tests in less than 75 minutes., Results: Two hundred eighteen (62%) patients completed the battery in 66 minutes on average. Mean interval from injury to testing was 28.3+/-7.1 days. Tests completed with the highest frequency were California Verbal Learning Test-II, FAS, and animal naming. Performance was less impaired (P<.001) on all measures for patients who had emerged from PTA., Conclusions: Approximately two thirds of screened patients were able to complete a brief neuropsychologic test battery at 2 to 6 weeks postinjury, regardless of PTA status. Although patients out of PTA were less impaired on all test measures, confusion did not preclude participation in the test battery or prohibit assignment of test scores. Early neuropsychologic assessment after TBI is feasible even for many patients who are still in PTA.

Objective: To investigate the prognostic significance of severity of post-traumatic confusion (PTC) and its constituent symptoms for early and late outcome after traumatic brain injury (TBI)., Design: Prospective cohort study., Setting: Inpatient brain injury rehabilitation program., Participants: A total of 168 patients meeting study criteria from 195 consecutive Traumatic Brain Injury Model Systems neurorehabilitation admissions., Interventions: Not applicable., Main Outcome Measures: Employability at neurorehabilitation discharge and productivity status at 1 year postinjury., Results: More severely confused patients had poorer outcomes for both employability and productivity. Multivariable logistic regression revealed that after adjustment for all other predictors, time to follow commands, and confusion severity predicted employability at discharge and age and confusion severity predicted productivity status at 1 year. Each symptom showed an unadjusted effect on discharge employability. All symptoms except nighttime sleep disturbance or daytime decreased arousal had effects on productivity at 1 year. Presence of psychotic-type symptoms was associated with especially poor productivity outcomes., Conclusions: PTC constituent symptoms and severity predict outcome after TBI. Presence or absence of psychotic-type symptoms on a single evaluation at approximately 21 days postinjury may have particular prognostic significance for productivity outcome.

Objective: To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI)., Design: Prospective cohort study., Setting: Acute inpatient TBI rehabilitation., Participants: Participants were 1748 persons with TBI., Interventions: Not applicable., Main Outcome Measures: Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation., Results: Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS., Conclusions: The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.