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Objective: To identify key variables that could predict risk of loss to follow-up (LTFU) in a nationally funded longitudinal database of persons with traumatic brain injury., Design: Secondary analysis of a prospective longitudinal cohort study., Setting: Traumatic Brain Injury Model System (TBIMS) Centers in the US., Participants: A total of 17,956 TBIMS participants (N=17,956) with interview status data available were included if eligible for 1-, 2-, 5-, 10-, 15-, or 20-year follow-ups between October 31, 1989, and September 30, 2020., Interventions: Not applicable., Main Outcome Measures: Follow-up data collection completion status at years 1, 2, 5, 10, 15, and 20., Results: Information relevant to participants' history, injury characteristics, rehabilitation stay, and patterns of follow-up across 20 years were considered using a series of logistic regression models. Overall, LTFU rates were low (consistently <20%). The most robust predictors of LTFU across models were missed earlier follow-ups and demographic factors including Hispanic ethnicity, lower education, and lack of private health insurance., Conclusions: Efforts to retain participants in such social disadvantaged or minority groups are encouraged given their disproportionate rate of LTFU. Repeated attempts to reach participants after a previously missed assessment are beneficial because many participants that missed 1 or more follow-ups were later recovered., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM., Design: Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range., Setting: Six TBI Model System rehabilitation hospitals., Participants: Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up., Interventions: Participants were administered the 49 assessment items in person or via telephone., Main Outcome Measures: Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance., Results: After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM., Conclusions: The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages., (Copyright © 2020 American Congress of Rehabilitation Medicine. 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 develop a set of composite scores that can be used for interpreting quality of life (QOL) after traumatic brain injury (TBI) using 9 of the patient-reported outcomes measures from the Traumatic Brain Injury Quality of Life (TBI-QOL) measurement system., Design: Participants completed 20 item banks from the TBI-QOL as part of a larger assessment. Composite index scores were created with normalized transformation with nonlinear area conversion using scores from 9 of the banks, and are expressed in index score units, with higher composite scores indicating better functioning. For descriptive purposes, associations among composites and individual banks were evaluated using regression, along with patterns of composite scores by injury severity groups using analysis of variance., Setting: Three medical centers in the United States., Participants: Community-dwelling adults (n=504) with a history of TBI., Interventions: Not applicable., Main Outcomes Measure: TBI-QOL., Results: Five composite indices were generated: global QOL, physical health, emotional health, cognitive health, and social health. Lookup tables are provided herein. Composite scores were highly intercorrelated (all r>.60, P<.0001), and individual TBI-QOL banks all correlate strongly with the global QOL composite in the expected direction (all r>.50, P<.0001)., Conclusion: Researchers and clinicians can use the TBI-QOL global QOL, physical health, emotional health, cognitive health, and social health composite scores to aggregate results from multiple TBI-QOL banks, which is anticipated to ease interpretation and reliability. This work additionally highlights the importance of considering nonphysical symptoms as outcomes variables for TBI research, as cognitive, social, and emotional domains were some of the most strongly correlated banks with the global QOL composite., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the factor structure of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system., Design: Observational., Setting: 3 TBI Model Systems rehabilitation centers., Participants: Twenty TBI-QOL item banks were administered to a sample of community-dwelling adults with TBI (N=504) as part of a study of TBI classification. A subsample of participants (n=200) was randomly selected for exploratory factor analyses, while data from the remaining participants (n=304) were used for the confirmatory factor analysis. To examine a wide range of conceptual models, confirmatory factor analyses were conducted on a total of 16 models, ranging from 1 to 7 factors., Interventions: Not applicable., Main Outcome Measures: Not applicable., Results: Initial exploratory factor analysis yielded support for a 5-factor model (negative emotion, cognitive impairment, functioning and participation, positive emotion, pain). Confirmatory factor analysis results, however, indicated a 7-factor model including physical function, physical symptoms, cognition, negative emotion, positive emotion, sense of self, and social participation (model 16; robust fit statistics root mean square error of approximation =.063, standardized root mean square residual =.035, comparative fit index =.955, Tucker-Lewis Index =.943, Bayes Information Criterion =40059.44)., Conclusions: The complex 7-factor model of the TBI-QOL provides a more nuanced framework for understanding health-related quality of life for persons with TBI than the commonly used 3-factor model including physical health, mental health, and social health., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a pain interference item bank, computer adaptive test (CAT), and short form for use by individuals with traumatic brain injury (TBI)., Design: Cross-sectional survey study., Setting: Five TBI Model Systems rehabilitation hospitals., Participants: Individuals with TBI (N=590)., Interventions: Not applicable., Outcome Measures: Traumatic Brain Injury-Quality of Life (TBI-QOL) Pain Interference item bank., Results: Confirmatory factor analysis provided evidence of a single underlying trait (χ 2 [740]=3254.030; P<.001; Comparative Fix Index=0.988; Tucker-Lewis Index=0.980; Root Mean Square Error of Approximation=0.076) and a graded response model (GRM) supported item fit of 40 Pain Interference items. Items did not exhibit differential item functioning or local item dependence. GRM calibration data were used to inform the selection of a 10-item static short form and to program a TBI-QOL Pain Interference CAT. Comparative analyses indicated excellent comparability and reliability across test administration formats., Conclusion: The 40-item TBI-QOL Pain Interference item bank demonstrated strong psychometric properties. End users can administer this measure as either a 10-item short form or CAT., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the responsiveness of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system., Design: Participants completed the 20 TBI-QOL item banks and the Participation Assessment with Recombined Tools-Objective (PART-O) Productivity Subscale at baseline and 6-month follow-up assessments. Participants were categorized into 4 groups (increased productivity, unchanged productivity, and decreased productivity) based on PART-O Productivity scores. Paired sample t tests were used to compare TBI-QOL scores at baseline and 6 months, and standardized response means and Cohen's d were computed to estimate effect sizes., Setting: Three traumatic brain injury (TBI) Model Systems rehabilitation centers in the United States., Participants: Two hundred one community-dwelling adults with TBI., Interventions: Not applicable., Main Outcome Measures: 20 TBI-QOL item banks., Results: As expected, given that there was no intervention, group mean TBI-QOL subdomain scores for the entire sample showed no change or small improvement over the 6-month study period. At the follow-up assessment, 72 participants reported increased productivity, 71 reported decreased productivity, and 58 reported the same level of productivity as they had 6 months prior. When compared with participants who reported unchanged or decreased productivity, participants who reported increased productivity on the PART-O subscale had clinically meaningful (d≥0.30) improvements on 7 TBI-QOL measures. The largest improvement was in the Independence subdomain (mean change, 7.06; df=0.84), with differences also observed in the Mobility, Positive Affect and Well-Being, Resilience, Grief/Loss, Ability to Participate, and Satisfaction with Participation subdomains., Conclusions: The 20 TBI-QOL item banks demonstrate responsiveness to change and measurement stability in a community-dwelling sample. Researchers may use the TBI-QOL to detect changes in HRQOL after a clinical intervention and clinicians may use it in their daily practices to monitor patient recovery., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop an item response theory (IRT)-calibrated, patient-reported outcome measure of subjective independence for individuals with traumatic brain injury (TBI)., Design: Large-scale item calibration field testing; confirmatory factor analysis (CFA) and graded response model IRT analyses., Setting: Five TBI Model System centers across the United States., Participants: Adults with complicated mild, moderate, or severe TBI (N=556)., Outcome Measures: Traumatic Brain Injury-Quality of Life (TBI-QOL) Independence item bank and the TBI-QOL Asking for Help scale., Results: A total of 556 individuals completed 44 items in the Independence item pool. Initial factor analyses indicated that items related to the idea of "asking for help" were measuring a different construct from other items in the pool. These 9 items were set aside. Twenty-two other items were removed because of bimodal distributions and/or low item-total correlations. CFA supported unidimensionality of the remaining Independence items. Graded response model IRT analysis was used to estimate slopes and thresholds for the final 13 Independence items. An 8-item fixed-length short form was also developed. The 9 Asking for Help items were analyzed separately. One misfitting item was deleted, and the final 8 items became a fixed-length IRT-calibrated scale. Reliability was high for both measures., Conclusions: The IRT-calibrated TBI-QOL Independence item bank and short form and TBI-QOL Asking for Help scale may be used to measure important issues for individuals with TBI in research and clinical applications., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop traumatic brain injury (TBI)-optimized versions of the Quality of Life in Neurological Disorders (Neuro-QoL) Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks, evaluate the psychometric properties of the item banks developed for adults with TBI, develop short form and computer adaptive test (CAT) versions, and report information to facilitate research and clinical applications., Design: We used a mixed methods design to develop and evaluate Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities items. Focus groups defined the constructs, cognitive interviews guided item revisions, and confirmatory factor analysis and item response theory methods helped calibrate item banks and evaluate differential item functioning related to demographic and injury characteristics., Setting: Five TBI Model Systems centers in the United States., Participants: Community-dwelling adults with TBI (N=556)., Interventions: None., Outcome Measures: Traumatic Brain Injury-Quality of Life (TBI-QOL) Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks., Results: Forty-five Ability to Participate in Social Roles and Activities and 41 Satisfaction with Social Roles and Activities items demonstrated good psychometric properties. Although some of the items are new, most were drawn from analogous banks in the Neuro-QoL measurement system. Consequently, the 2 TBI-QOL item banks were linked to the Neuro-QoL metric, and scores are comparable with the general population. All CAT and short forms correlated highly (>0.90) with the full item banks and demonstrate comparable construct coverage and measurement error., Conclusion: The TBI-QOL Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks are TBI-optimized versions of the Neuro-QoL Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks and demonstrate excellent measurement properties in individuals with TBI. These measures, particularly in CAT or short form format, are suitable for efficient and precise measurement of social outcomes in clinical and research applications., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The first aim of this study was to develop a Rasch-based crosswalk between 2 postconcussive symptom measures, the Neurobehavioral Symptom Inventory (NSI) and the Rivermead Postconcussive Symptom Questionnaire (RPQ). The second goal was to utilize Rasch analysis to formulate a new proposed scale containing the best theoretical and psychometric items., Design: Prospective cohort observational study., Setting: Three acute inpatient rehabilitation hospitals in the United States., Participants: Community-dwelling persons (N=497) who were previously hospitalized and were diagnosed with mild to severe traumatic brain injury. Participants were (1) 18-64 years old; (2) could give informed consent; (3) able to complete study measures in English; (4) did not have an interfering medical or psychiatric condition., Interventions: Not applicable., Main Outcome Measures: NSI, RPQ., Results: Rasch analysis revealed 4 subdimensions across the 2 scales: cognitive, affective, physical, and visual. Crosswalk tables were generated for the first 3. Visual items were too few to generate a crosswalk. Iterative Rasch analysis produced a new scale with items rated from none to severe including the best items in each of these dimensions., Conclusions: The NSI and RPQ have considerable overlap and measure the same overarching constructs. Crosswalk tables may be helpful for clinicians and researchers to convert scores from 1 measure to the other. A more psychometrically sound scale, the Brain Injury Symptom Scale, composed of items from the NSI and RPQ, is proposed and will need further validation., (Published by Elsevier Inc.)

Objective: To compare patient functional outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers using an enhanced statistical model and to determine factors that influence those outcomes., Design: Multicenter observational cohort study., Setting: TBIMS centers., Participants: Patients with traumatic brain injury (TBI) admitted to 19 TBIMS rehabilitation centers from 2003-2012 (N=5505)., Interventions: Not applicable., Main Outcome Measures: Functional outcomes of patients with TBI., Results: Individuals with lower functional status at the time of admission, longer duration of posttraumatic amnesia, and higher burden of medical comorbidities continued to have worse functional outcomes at discharge from inpatient rehabilitation and at the 1-year follow-up, whereas those who were employed at the time of injury had better outcomes at both time periods. Risk-adjusted patient functional outcomes for patients in most TBIMS centers were consistent with previous research. However, there were wide performance differences for a few centers even after using more recently collected data, improving on the regression models by adding predictors known to influence functional outcomes, and using bootstrapping to eliminate confounds., Conclusions: Specific patient, injury, and clinical factors are associated with differences in functional outcomes within and across TBIMS rehabilitation centers. However, these factors did not explain all the variance in patient outcomes, suggesting a role of some other predictors that remain unknown., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009., Design: Secondary data analysis., Setting: Inpatient rehabilitation centers., Participants: Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10., Interventions: Not applicable., Main Outcomes Measure: Employment., Results: Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury., Conclusions: These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the accuracy of self-reported length of coma and posttraumatic amnesia (PTA) in persons with medically verified traumatic brain injury (TBI) and to investigate factors that affect self-report of length of coma and PTA duration., Design: Prospective cohort study., Setting: Specialized rehabilitation center with inpatient and outpatient programs., Participants: Persons (N=242) with medically verified TBI who were identified from a registry of persons who had previously participated in TBI-related research., Intervention: Not applicable., Main Outcome Measures: Self-reported length of coma and self-reported PTA duration., Results: Review of medical records revealed that the mean medically documented length of coma and PTA duration was 6.9±12 and 19.2±22 days, respectively, and the mean self-reported length of coma and PTA duration was 16.7±22 and 106±194 days, respectively. The average discrepancy between self-report and medical record for length of coma and PTA duration was 8.2±21 and 64±176 days, respectively. Multivariable regression models revealed that time since injury, performance on cognitive tests, and medical record values were associated with self-reported values for both length of coma and PTA duration., Conclusions: In this investigation, persons with medically verified TBI showed poor accuracy in their self-report of length of coma and PTA duration. Discrepancies were large enough to affect injury severity classification. Caution should be exercised when considering self-report of length of coma and PTA duration., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To conduct a systematic review of the prognostic value of self-reported traits/problems/strengths and environmental barriers/facilitators for participation outcomes in persons with traumatic brain injury (TBI)., Data Sources: Articles published through August 15, 2013, obtained by conducting electronic searches of PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature databases and a review of reference lists of reviewed articles., Study Selection: Reviewed articles were written in English and presented findings on adult humans with TBI, participation outcomes, and ≥ 1 self-reported trait/problem/strength (eg, depression, pain, coping style) and/or ≥ 1 environment barrier/facilitator (eg, social support, family functioning, access to services)., Data Extraction: Each of the 996 abstracts was examined by 2 reviewers, and those failing to meet all inclusion criteria were excluded. Data were extracted from the 63 retained articles by 2 independent reviewers, who met to resolve any differences in study quality rating or evidence recorded. Study quality was determined using American Academy of Neurology (AAN) criteria., Data Synthesis: Conclusions regarding prognostic importance of self-report and environmental barrier/facilitator variables were made using AAN criteria. Conclusions regarding barrier/facilitator variables indicated that access to transportation, access to services, and participation in social interaction were possibly predictive of employment outcome, whereas living arrangements and social support were possibly not predictive of employment outcome. Conclusions regarding self-report variables indicated that the number of postconcussive symptoms, fatigue, and physical competence were probably predictive of employment and need for supervision, whereas self-efficacy was probably not predictive of employment. Subjective well-being, pain, and social interaction were possibly predictive of employment, whereas coping style was possibly not predictive., Conclusions: Although additional investigation is needed, self-report variables are likely to make important contributions to predicting participation outcomes. Future research should be guided by coherent conceptual models and use a consistent set of assessment instruments to facilitate comparisons between studies., (Copyright © 2014 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 predictive value of preinjury factors for satisfaction with life (SWL) at 1-year posttraumatic brain injury (TBI)., Design: Secondary analysis of prospective, longitudinal registry using data collected during inpatient rehabilitation and at 1-year post-TBI., Setting: Fifteen specialized brain injury units providing acute rehabilitation care as part of the Traumatic Brain Injury Model Systems (TBIMS) program., Participants: Community-dwelling persons (N=444) with moderate to severe TBI aged 16 to 64 years enrolled in the TBIMS program between October 2007 and October 2008 with 1-year follow-up data., Interventions: Not applicable., Main Outcome Measure: Satisfaction With Life Scale (SWLS)., Results: Hierarchical stepwise linear regression revealed that injury-related and demographic variables did not contribute significantly to the explained variance in SWLS scores. In contrast, the preinjury functioning (education, productivity/employment) and preinjury condition (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI) blocks each contributed significantly to the explained variance in SWLS scores. Preinjury functioning accounted for 2.9% of the variance and preinjury conditions for 3.8%., Conclusions: Although their contributions are small, preinjury functioning and preinjury conditions are important to consider in the prediction of SWL post-TBI. Educational level and history of psychiatric and other premorbid difficulties are particularly important for clinicians to consider when implementing or developing interventions for persons with moderate to severe TBI., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals., Design: Prospective cohort study., Setting: Community., Participants: Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community., Interventions: None., Main Outcome Measures: Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals., Results: Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all., Conclusions: Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This article presents a 3-part framework for developing and evaluating prediction models in rehabilitation populations. First, a process for developing and refining prognostic research questions and the scientific approach to prediction models is presented. Primary components of the scientific approach include the study design and sampling of patients, outcome measurement, selecting predictor variable(s), minimizing methodologic sources of bias, assuring a sufficient sample size for statistical power, and selecting an appropriate statistical model. Examples focus on prediction modeling using samples of rehabilitation patients. Second, a brief overview for statistically building and validating multivariable prediction models is provided, which includes the following 7 steps: data inspection, coding of predictors, model specification, model estimation, model performance, model validation, and model presentation. Third, we propose a set of primary considerations for evaluating prediction model studies using specific quality indicators as criteria to help stakeholders evaluate the quality of a prediction model study. Lastly, we offer perspectives on the future development and use of rehabilitation prediction models., (Copyright © 2012 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.)

The research literature that rehabilitation clinicians need to be familiar with has become too large for anyone to read, and numerous published studies are too complex for many practitioners to understand and fruitfully use. One method to keep up with new findings is through systematic reviews. Systematic reviews can be effective tools that help guide rehabilitation practice by identifying the best research that provides the evidence for enhanced clinical decision-making. This article describes how systematic reviews are created, indicates where rehabilitation clinicians may find them, and refers to a resource that may be of use in evaluating their quality and applicability., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of a Scheduled Telephone Intervention (STI) compared with usual care (UC) on function, health/emotional status, community/work activities, and well-being at 1 and 2 years after traumatic brain injury (TBI)., Design: Two group, randomized controlled trial., Setting: Telephone contacts with subjects recruited in inpatient rehabilitation., Participants: Eligible subjects (N=433) with TBI (age>16y) were randomly assigned to STI plus UC (n=210) or UC (n=223) at discharge. STI subjects (n=169) completed the outcome at year 1 (118 at year 2) and 174 UC subjects at year 1 (123 at year 2)., Interventions: STI subjects received calls at 2 and 4 weeks and 2, 3, 5, 7, 9, 12, 15, 18, and 21 months consisting of brief training in problem solving, education, or referral., Main Outcome Measures: A composite outcome at 1 year was the primary endpoint. Analysis on intent-to-treat basis used linear regression adjusted for site, Glasgow Coma Scale, race/ethnicity, age, FIM, sex, and Disability Rating Scale (DRS). Secondary analyses were conducted on individual and composite measures (FIM, DRS, community participation indicators, Glasgow Outcome Scale [Extended], Short Form-12 Health Survey, Brief Symptom Inventory-18, EuroQOL, and modified Perceived Quality of Life)., Results: No significant differences were noted between the groups at years 1 or 2 for primary (P=.987 regression for year 1, P=.983 for year 2) or secondary analyses., Conclusions: This study failed to replicate the findings of a previous single center study of telephone-based counseling. While telephone mediated treatment has shown promise in other studies, this model of flexible counseling in problem solving and education for varied problems was not effective over and above usual care., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To conduct a systematic review of behavioral assessment scales for disorders of consciousness (DOC); provide evidence-based recommendations for clinical use based on their content validity, reliability, diagnostic validity, and ability to predict functional outcomes; and provide research recommendations on DOC scale development and validation., Data Sources: Articles published through March 31, 2009, using MEDLINE, CINAHL, Psychology and Behavioral Sciences Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Biomedical Reference Collection, and PsycINFO. Thirteen primary terms that defined DOC were paired with 30 secondary terms that defined aspects of measurement. Scale names, abbreviations, and authors were also used as search terms. Task force members identified additional articles by using personal knowledge and examination of references in reviewed articles., Study Selection: Primary criteria included the following: (1) provided reliability, diagnostic validity, and/or prognostic validity data; (2) examined a cohort, case control, or case series sample of persons with DOC who were age older than or equal to 18 years; and (3) assessed in an acute care or rehabilitation setting. Articles were excluded if peer review was not conducted, original data were not reported, or an English language article was not available. The initial search yielded 580 articles. After paired rater review of study abstracts, guideline development was based on 37 articles representing 13 DOC scales., Data Extraction: Rater pairs classified studies addressing diagnostic and prognostic validity by using the American Academy of Neurology 4-tier level of evidence scheme, and reliability by using a task force-developed 3-tier evidence scheme. An independent quality review of ratings was conducted, and corrections were made., Data Synthesis: The Coma Recovery Scale-Revised (CRS-R), Sensory Stimulation Assessment Measure (SSAM), Wessex Head Injury Matrix (WHIM), Western Neuro Sensory Stimulation Profile (WNSSP), Sensory Modality Assessment Technique (SMART), Disorders of Consciousness Scale (DOCS), and Coma/Near-Coma Scale (CNC) have acceptable standardized administration and scoring procedures. The CRS-R has excellent content validity and is the only scale to address all Aspen Workgroup criteria. The SMART, SSAM, WHIM, and WNSSP demonstrate good content validity, containing items that could distinguish persons who are in a vegetative state, are in a minimally conscious state (MCS), or have emerged from MCS. The Full Outline of UnResponsiveness Score (FOUR), WNSSP, CRS-R, Comprehensive Levels of Consciousness Scale (CLOCS), and Innsbruck Coma Scale (INNS) showed substantial evidence of internal consistency. The FOUR and the CRS-R showed substantial evidence of good interrater reliability. Evidence of diagnostic validity and prognostic validity in brain injury survivor samples had very high levels of potential bias because of methodologic issues such as lack of rater masking., Conclusions: The CRS-R may be used to assess DOC with minor reservations, and the SMART, WNSSP, SSAM, WHIM, and DOCS may be used to assess DOC with moderate reservations. The CNC may be used to assess DOC with major reservations. The FOUR, INNS, Glasgow-Liege Coma Scale, Swedish Reaction Level Scale-1985, Loewenstein Communication Scale, and CLOCS are not recommended at this time for bedside behavioral assessment of DOC because of a lack of content validity, lack of standardization, and/or unproven reliability., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This article summarizes the selection of outcome measures by the interagency Traumatic Brain Injury (TBI) Outcomes Workgroup to address primary clinical research objectives, including documentation of the natural course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements Workgroups, the TBI Outcomes Workgroup adopted the standard 3-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in TBI from each identified domain, including global level of function, neuropsychological impairment, psychological status, TBI-related symptoms, executive functions, cognitive and physical activity limitations, social role participation, and perceived health-related quality of life. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to some older ("legacy") measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges., (Copyright © 2010 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.

Objective: To examine the predictive validity of a brief neuropsychologic test battery consisting of the Galveston Orientation and Amnesia Test, the California Verbal Learning Test-II, Trail-Making Test (TMT), Symbol Digit Modalities Test, grooved pegboard, phonemic and categorical word generation tasks, the Wechsler Test of Adult Reading (WTAR), and the Wisconsin Card Sorting Test-64 relative to functional outcome at 1 year in persons with traumatic brain injury., Design: Inception cohort study. Follow-up period of 12 months., Setting: Seven Traumatic Brain Injury Model System centers. Neuropsychologic testing was conducted during the acute inpatient rehabilitation stay and functional outcome measures were obtained at 1-year outpatient follow-up., Participants: Adults (N=174) who met criteria for admission to inpatient brain injury rehabilitation., Interventions: Not applicable., Main Outcome Measures: FIM instrument, Disability Rating Scale, Supervision Rating Scale, Satisfaction With Life Scale (SWLS), and Glasgow Outcome Scale-Extended., Results: Multiple regression analyses revealed that performance on the neuropsychologic test battery was predictive of outcome at 1 year postinjury for all outcome measures, except FIM motor scores and the SWLS. Cognitive performance using this battery was found to predict 1-year outcomes above and beyond functional variables and injury severity variables collected during inpatient rehabilitation, thereby indicating incremental validity for this test battery. Individual tests that were found to be significant predictors of 1-year outcomes included the WTAR and TMT part B., Conclusions: These findings support the clinical utility and ecological validity of this battery with respect to level of disability, functional independence, and supervision required.

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 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.

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 examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI)., Design: Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design., Setting: Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital., Participants: Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29)., Interventions: Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community., Main Outcome Measures: Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire., Results: All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge., Conclusions: The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.

Objectives: To describe the phenomenology of posttraumatic confusional state (PTCS) and to provide preliminary validation of a new procedure, the Confusion Assessment Protocol (CAP), for assessing PTCS., Design: Criterion standard investigation., Setting: Inpatient traumatic brain injury (TBI) rehabilitation program., Participants: Two consecutive series of patients (n=62, n=93) with TBI admitted for inpatient rehabilitation., Interventions: Not applicable., Main Outcome Measures: Clinical diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, classification of posttraumatic amnesia (PTA) based on the Galveston Orientation and Amnesia Test (GOAT), and Disability Rating Scale score at time of rehabilitation hospital discharge. Results Agreement between the diagnosis of PTCS with the CAP and DSM-IV classification of delirium was 87%, and agreement between PTCS and PTA using GOAT criteria was 90%. Patients classified as in PTCS sustained more severe injuries and required longer rehabilitation stays. Confusion status was associated with poorer functional status at rehabilitation discharge., Conclusions: The CAP is a brief, structured, repeatable measure of multiple neurobehavioral aspects of PTCS. Confusion status as determined by CAP assessment contributed to prediction of outcome at rehabilitation discharge after adjustment for other potential predictors.

Objective: To compare awareness of deficit in 3 domains of function (physical, cognitive, behavioral/emotional) in acute traumatic brain injury (TBI), controlling for severity of impairment in the different domains., Design: Inception cohort., Setting: Three inpatient rehabilitation programs., Participants: People with acute TBI (N=161), tested as soon as feasible after posttraumatic amnesia., Interventions: Not applicable., Main Outcome Measures: Awareness Questionnaire (AQ) completed by the person with TBI and the treating neuropsychologist; and self- and clinician-rating scores calculated in the 3 domains., Results: For participants who were rated by clinicians as more impaired in at least 1 domain (ie, scored lower on the AQ), self-ratings differed significantly from one another in all 3 domains, with behavioral self-ratings highest, physical self-ratings lowest, and cognitive self-ratings intermediate. In subgroups of participants rated at the same level by clinicians in all 3 domains, physical self-ratings were also lowest, that is, more consonant with clinician ratings. Participants tended to rate themselves as relatively unchanged in cognitive and behavioral domains regardless of the level of clinician ratings on these factors., Conclusions: Patterns of discrepant awareness of deficit in different functional areas seen in postacute TBI also appear to be present acutely and are not entirely related to differential severity of deficit. We discuss several possible reasons for discrepant awareness of deficit, including differences in internal and external feedback, cultural and psychologic factors, and different levels of ambiguity inherent in causal explanations for different types of problems.

Objective: To determine concordance between patient and family report of neurobehavioral symptoms and problems across 6 domains of function and 3 levels of injury severity at 1 year after traumatic brain injury (TBI)., Design: Prospective longitudinal design with follow-up between 10 and 14 months postinjury., Setting: Seventeen Traumatic Brain Injury Model Systems centers., Participants: A total of 267 adults with primarily moderate and severe TBI who had completed self-ratings and whose neurobehavioral symptoms had also been rated by their significant others., Interventions: Not applicable., Main Outcome Measures: Neurobehavioral Functioning Inventory-Revised, a 70-item scale with subscales assessing frequency of symptoms in motor, somatic, memory and attention, depression, communication, and aggression domains., Results: Twenty-three items showed significant differences or trends between the self- and other ratings; 18 of these were in the direction of the injured individual reporting less frequent problems. Differences were most pronounced on the depression, aggression, and memory and attention subscales. On the latter 2 subscales, patient-family concordance was higher for those with less severe injuries. However, severity effects were not clear cut. Analyses of selected rating patterns indicating clinically significant "underreporting" of symptoms revealed that these affected the depression, aggression, and memory and attention subscales more than the motor or somatic subscales., Conclusions: At 1 year post-TBI, concordance between self- and other report of neurobehavioral symptoms was moderately high overall, but varied by symptom domain. For persons with moderate and severe TBI, reports from significant others may be needed for a full picture of the range, severity, and clinical importance of the patient's emotional, behavioral, and cognitive difficulties.

Objective: To characterize the preinjury family functioning, emotional distress, and social support of caregivers of persons with traumatic brain injury (TBI)., Design: Inception cohort., Setting: Three Traumatic Brain Injury Model Systems centers' inpatient rehabilitation facilities., Participants: One hundred ninety-one caregivers, primarily white and female, of persons with TBI., Interventions: Not applicable., Main Outcome Measures: The Brief Symptom Inventory, Family Assessment Device, Multidimensional Scale of Perceived Social Support, and history of medical and psychiatric illness., Results: Thirty-seven percent of caregivers indicated symptoms of emotional distress consistent with psychiatric diagnoses for the month before injury, whereas 27% reported a history of psychiatric or psychologic treatment at some point in the past. Between 25% and 33% of caregivers reported unhealthy family functioning in 1 or more areas for the month before injury. Persons with an annual income less than US dollars 10,000 reported less healthy preinjury family functioning. Caregivers reported good satisfaction with preinjury social support, and very few caregivers reported a history of substance abuse., Conclusion: A substantial proportion of caregivers reported emotional distress and/or unhealthy family functioning before injury. Such difficulties may make them more vulnerable to the stress associated with injury and result in greater coping difficulties.

Objectives: To evaluate predictors of early impaired self-awareness after traumatic brain injury (TBI); to examine interrelationships of the perceptions of patient, clinician, family, and significant other of how patients are functioning after TBI; and to determine how early impaired self-awareness helps to predict employability at rehabilitation discharge., Design: Inception cohort., Setting: Two inpatient rehabilitation programs., Participants: A total of 129 patients with TBI seen for inpatient rehabilitation at 1 of 2 rehabilitation centers. All subjects had emerged from posttraumatic amnesia before being assessed for this study., Interventions: Not applicable., Main Outcome Measures: Impaired self-awareness as measured by the Awareness Questionnaire (patient self-ratings, clinician ratings) and employability (rated on the Disability Rating Scale) at discharge from inpatient rehabilitation., Results: Regression analysis revealed that early impaired self-awareness was predicted by age and functional status (FIM instrument total score) at admission to inpatient rehabilitation. Spearman correlation coefficients revealed that clinician, family, and significant other ratings of patient functioning were related (r(s) =.42, P<.001), but were not related to patient self-ratings. Multiple logistic regression analysis revealed that early impaired self-awareness was predictive of employability at discharge from inpatient rehabilitation. Clinician ratings of patient functioning showed a positive relation to employability (P =.05), whereas patient self-ratings showed a trend toward a negative relation to employability (P =.09)., Conclusions: Our results support the importance of early impaired self-awareness assessment, its predictive value for complex functional activities, and the need for further research to determine if treatment programs for impaired self-awareness enhance functional outcomes.

Objective: To evaluate the contribution of early cognitive assessment to the prediction of productivity outcome after traumatic brain injury (TBI) adjusted for severity of injury, demographic factors, and preinjury employment status., Design: Inception cohort., Setting: Six inpatient brain injury rehabilitation programs., Participants: A total of 388 adults with TBI whose posttraumatic amnesia (PTA) resolved before discharge from inpatient rehabilitation., Interventions: Administered neuropsychologic tests during inpatient stay on emergence from PTA. Follow-up interview and evaluation. Predictor measures also determined., Main Outcome Measure: Productivity status at follow-up 12 months postinjury., Results: Multiple logistic regression analysis revealed that preinjury productivity status, duration of PTA, education level, and early cognitive status each made significant, independent contributions to the prediction of productivity status at follow-up. When adjusted for all other predictors, persons scoring at the 75th percentile on early cognitive status (less impaired) had 1.61 times greater odds (95% confidence interval [CI], 1.07-2.41) of being productive follow-up than those scoring at the 25th percentile (more impaired). Without adjustment, persons scoring at the 75th percentile had 2.46 times greater odds (95% CI, 1.77-3.43) of being productive at follow-up., Conclusions: Findings support the utility of early cognitive assessment by using neuropsychologic tests. In addition to other benefits, early cognitive assessment makes an independent contribution to prediction of late outcome. Findings support the clinical practice of performing initial neuropsychologic evaluations after resolution of PTA., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)