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Background: Individuals with traumatic brain injury (TBI) often develop sleep disorders post-injury. The most common one is insomnia, which can exacerbate other post-injury symptoms, including fatigue, impaired cognition, depression, anxiety, and pain. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a manualized treatment that effectively treats insomnia with secondary effects on cognition, mood, and pain in various populations., Objective: This paper reviews the use of CBT-I for three participants with TBI of different severities., Methods: Pre- and post-treatment assessments of insomnia, fatigue, depression, anxiety, and pain were conducted. Mood was further assessed at follow-up. Minimal clinically important difference (MCID) scores derived from the research literature were used to establish clinically meaningful symptom improvement on self-report questionnaires., Results: The reduction in insomnia severity scores for all three participants were not large enough to be considered a clinically significant improvement following CBT-I, although trends toward improvement were observed. However, all participants showed clinically significant reductions in anxiety at post-treatment; the effects persisted for 2 participants at follow-up. Reductions in depression symptoms were observed for 2 participants at post-treatment, and treatment effects persisted for 1 participant at follow-up. One participant endorsed clinically significant improvements in fatigue and pain severity., Conclusions: We conclude that CBT-I may provide secondary benefits for symptoms commonly experienced by individuals with TBI, especially mood disturbances.

Objectives: (a) Identify life satisfaction trajectories after moderate to severe traumatic brain injury (TBI); (b) establish a predictive model for these trajectories across the first 5 years postinjury; and (c) describe differences in these life satisfaction trajectory groups, focusing on age, depressive symptoms, disability, and participation in specific life roles., Research Method: Analysis of the longitudinal TBI Model Systems National Database was performed on data collected prospectively at 1-, 2-, and 5-years post-TBI. Participants (n = 3,012) had a moderate to severe TBI and were 16 years old and older., Results: Four life satisfaction trajectories were identified across the first 5 years postinjury, including: stable satisfaction, initial satisfaction declining, initial dissatisfaction improving, and stable dissatisfaction. Age, depressive symptoms, cognitive disability, and life role participation as a worker, leisure participant, and/ or religious participant at 1-year postinjury significantly predicted trajectory group membership. Life role participation and depressive symptoms were strong predictors of life satisfaction trajectories across the first 5 years post-TBI., Conclusions: The previously documented loss of life roles and prevalence of depression after a moderate to severe TBI make this a vulnerable population for whom low or declining life satisfaction is a particularly high risk. Examining individual life role participation may help to identify relevant foci for community-based rehabilitation interventions or supports., ((c) 2015 APA, all rights reserved).)

Objective: To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort., Design: Prospective, multicenter, longitudinal cohort study., Setting: Acute TBI rehabilitation programs., Participants: Patients (N=1946) receiving 138,555 therapy sessions., Interventions: Not applicable., Main Outcome Measures: Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS)., Results: The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001)., Conclusions: Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population., Design: Prospective, longitudinal, observational study., Setting: Ten inpatient rehabilitation centers., Participants: Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury., Interventions: Not applicable., Main Outcome Measures: Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being., Results: The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations., Conclusions: This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This supplement of the Archives of Physical Medicine and Rehabilitation is devoted to the Traumatic Brain Injury-Practice Based Evidence study, the first practice-based evidence study, to our knowledge, of traumatic brain injury rehabilitation. The purpose of this preface is to place this study in the broader context of comparative effectiveness research and introduce the articles in the supplement., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and to assess the relations of group therapy with patient, injury, and treatment factors and outcomes., Design: Prospective observational cohort., Setting: Inpatient rehabilitation., Participants: Consecutive admissions (N=2130) for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in the United States, 1 in Canada) from October 2008 to September 2011., Interventions: Not applicable., Main Outcome Measures: Proportion of sessions that were group therapy (≥2 patients were treated simultaneously by ≥1 clinician); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay; discharge location; and FIM cognitive and motor scores at discharge., Results: Of the patients, 79% received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9h/wk in group therapy. The greatest proportion of treatment time in group format was in therapeutic recreation (25.6%), followed by speech therapy (16.2%), occupational therapy (10.4%), psychology (8.1%), and physical therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with the treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied., Conclusions: Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percentage of therapy time delivered in groups., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the use of occupational therapy (OT), physical therapy (PT), and speech therapy (ST) treatment activities throughout the acute rehabilitation stay of patients with traumatic brain injury., Design: Multisite prospective observational cohort study., Setting: Inpatient rehabilitation settings., Participants: Patients (N=2130) admitted for initial acute rehabilitation after traumatic brain injury. Patients were categorized on the basis of admission FIM cognitive scores, resulting in 5 fairly homogeneous cognitive groups., Interventions: Not applicable., Main Outcome Measures: Percentage of patients engaged in specific activities and mean time patients engaged in these activities for each 10-hour block of time for OT, PT, and ST combined., Results: Therapy activities in OT, PT, and ST across all 5 cognitive groups had a primary focus on basic activities. Although advanced activities occurred in each discipline and within each cognitive group, these advanced activities occurred with fewer patients and usually only toward the end of the rehabilitation stay., Conclusions: The pattern of activities engaged in was both similar to and different from patterns seen in previous practice-based evidence studies with different rehabilitation diagnostic groups., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To conduct a systematic review of the evidence on interventions for posttraumatic brain injury fatigue (PTBIF)., Methods: Systematic searches of multiple databases for peer-reviewed studies published in English on interventions targeting PTBIF as a primary or secondary outcome through January 22, 2014. Reference sections were also reviewed to identify additional articles. Articles were rated using the 2011 American Academy of Neurology Classification of Evidence Scheme for therapeutic studies., Results: The searches yielded 1526 articles. Nineteen articles met all inclusion criteria: 4 class I, 1 class II/III, 10 class III, and 4 class IV. Only 5 articles examined fatigue as a primary outcome. Interventions were pharmacological and psychological or involved physical activity, bright blue light, electroencephalographic biofeedback, or electrical stimulation. Only 2 interventions (modafinil and cognitive behavioral therapy with fatigue management) were evaluated in more than 1 study., Conclusions: Despite areas of promise, there is insufficient evidence to recommend or contraindicate any treatments of PTBIF. Modafinil is not likely to be effective for PTBIF. Piracetam may reduce it, as may bright blue light. Cognitive behavioral therapy deserves additional study. High-quality research incorporating appropriate definition and measurement of fatigue is required to explore the potential benefits of promising interventions, evaluate fatigue treatments shown to be effective in other populations, and develop new interventions for PTBIF.

Objective: To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI)., Setting: Diverse community settings., Participants: Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396)., Design: Cross-sectional., Main Measure: Brain Injury Screening Questionnaire., Results: Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms., Conclusion: Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Objective: To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI)., Design: Randomized, waitlist controlled trial with minimization and blinded outcome assessment., Setting: Community., Participants: Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white)., Intervention: STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training., Main Outcome Measures: Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life., Results: Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life., Conclusions: The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To gain an understanding of clinical thought processes about treatment classification and description, and to identify desired characteristics of and challenges to be addressed by a future rehabilitation treatment taxonomy., Design: Qualitative analysis of data collected via focus groups and semistructured interviews., Setting: Inpatient rehabilitation programs., Participants: Clinicians (N=84) in 7 disciplines involved in data collection for practice-based evidence studies of spinal cord injury and traumatic brain injury rehabilitation., Interventions: Not applicable., Main Outcome Measure: Summary of themes reported by clinicians, determined by content analysis of focus group and interview transcripts., Results: The multifaceted nature of rehabilitation treatment was identified as a major challenge to the process of classifying interventions. Simultaneous delivery of multiple interventions, performance of integrated tasks that challenge multiple body systems, and conversation-based treatments were reported to be difficult to classify. Clinicians reported that treatment classifications that make reference to goals of treatment were clinically intuitive, but they also reported difficulties when attempting to classify activities that could address multiple goals. These rehabilitation practitioners considered the setting in which treatment occurs, equipment used, assistance or cueing provided, type of treatment participants, and specific tasks performed to be important descriptors of their interventions. They recommended creating a classification system that can be applied at greater or lesser levels of detail depending on the purpose for which it is being used., Conclusions: Treatment descriptors identified may be useful for differentiating classes of treatments or characterizing treatments within classes. Precise definition of the concept of the goal as it relates to treatment theory and definition of boundaries between treatments may aid classification of multifaceted treatment activities. A balance between detail and feasibility of use will facilitate successful clinical application of a future classification system., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the psychometric properties of the Multidimensional Assessment of Fatigue (MAF) scale in a traumatic brain injury (TBI) sample., Design: Prospective survey study., Setting: Community., Participants: One hundred sixty-seven individuals with TBI admitted for inpatient rehabilitation, enrolled into the TBI Model Systems national database, and followed up at either the first or second year postinjury., Interventions: Not applicable., Main Outcome Measure(s): Multidimensional Assessment of Fatigue., Results: The initial analysis, using items 1 to 14, which are based on a 10-point rating scale, found that only 1 item ("walking") misfit the overall construct of fatigue in this TBI population. However, this 10-point rating scale was found to have disordered thresholds. When ratings were collapsed into 4 response categories, all MAF items used to calculate the Global Fatigue Index formed a unidimensional scale., Conclusion(s): Findings generally support the unidimensionality of the MAF when used in a TBI population but call into question the use of a 10-point rating scale for items 1 to 14. Further study is needed to investigate the use of a 4-category rating scale across all items and the fit of the "walking" item for a measure of fatigue among individuals with TBI.

Objective: To determine whether the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) is representative of individuals aged 16 years and older admitted for acute, inpatient rehabilitation in the United States with a primary diagnosis of traumatic brain injury (TBI)., Design: Secondary analysis of existing data sets., Setting: Acute inpatient rehabilitation facilities., Participants: Patients aged 16 years and older with a primary rehabilitation diagnosis of TBI., Main Outcome Measures: Demographic characteristics, functional status, and hospital length of stay., Results: Patients included in the TBIMS-NDB from October 2001 through December 2007 were largely representative of all individuals 16 years and older admitted for rehabilitation in the United States with a primary diagnosis of TBI. The major difference in distribution was age-the TBIMS-NDB cohort did not include as large a proportion of patients older than 65 years as were admitted for rehabilitation with a primary diagnosis of TBI in the United States. Distributional differences for age-related characteristics were observed; however, groups of patients partitioned at aged 65 years differed minimally, especially within the younger than 65 years subset. Regardless of age, the proportion of patients with a rehabilitation stay of 1 to 9 days was larger nationwide. Nationwide admissions showed an age distribution similar to patients discharged alive from acute care with moderate, severe or penetrating TBI. The proportion of patients aged 70 years and older admitted for TBI rehabilitation in the United States increased every year, a trend that was not evident in the general population, TBIMS-NDB or among TBI patients in acute care., Conclusions: These results provide substantial empirical evidence that the TBIMS-NDB is representative of patients receiving inpatient rehabilitation for TBI in the United States. Researchers utilizing the TBIMS-NDB may want to adjust statistically for the lower percentage of patients older than 65 years or those with stays less than 10 days.

Objective: To characterize overall and cause-specific mortality and life expectancy among persons who have completed inpatient traumatic brain injury rehabilitation and to assess risk factors for mortality., Design: Prospective cohort study., Setting: The Traumatic Brain Injury Model Systems., Participants: A total of 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined., Interventions: Not applicable., Main Outcome Measures: Standardized mortality ratio (SMR), life expectancy, cause of death., Results: SMR was 2.25 overall and was significantly elevated for all age groups, both sexes, all race/ethnic groups (except Native Americans), and all injury severity groups. SMR decreased as survival time increased but remained elevated even after 10 years postinjury. SMR was elevated for all cause-of-death categories but especially so for seizures, aspiration pneumonia, sepsis, accidental poisonings, and falls. Life expectancy was shortened an average of 6.7 years. Multivariate Cox regression showed age at injury, sex, race/ethnic group, marital status and employment status at the time of injury year of injury, preinjury drug use, days unconscious, functional independence and disability on rehabilitation discharge, and comorbid spinal cord injury to be independent risk factors for death., Conclusion: There is an increased risk of death after moderate or severe traumatic brain injury. Risk factors and causes of death have been identified that may be amenable to intervention.

Objective: To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes., Design: Cross-sectional study., Setting: Five National Institute of Disability and Rehabilitation Research TBI Model Systems., Participants: Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012., Main Outcome Results: Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals., Conclusions: Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF.

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 determine whether use of neighborhood characteristics derived from U.S. Census Bureau information contributes to the prediction of outcomes after traumatic brain injury (TBI) beyond the variance accounted for by individual characteristics., Design: Cross-sectional analysis of follow-up interviews conducted 1, 2, and 5 years postinjury., Setting: Twelve Traumatic Brain Injury Model Systems (TBIMS) centers., Participants: Patients 16 years of age and older with moderate or severe TBI enrolled in the TBIMS National Database (N=472)., Interventions: None., Main Outcome Measures: Satisfaction With Life Scale and Participation Assessment with Recombined Tools-Objective., Results: Individual characteristics alone accounted for 26% and 48% of variance in life satisfaction and participation, respectively; neighborhood characteristics alone accounted for 6% and 9% of variance, respectively. Models combining both types of characteristics included significant neighborhood and individual predictors for participation but not life satisfaction; however, for participation, prediction only improved beyond that found for individual characteristics alone by 1.2%., Conclusions: The results did not support the hypotheses that characteristics of a person's neighborhood would increase outcome prediction beyond that which can be accomplished based on characteristics of the individual alone. Though neighborhood characteristics were statistically significant in prediction models, the improvement in percent of variance accounted for was negligible. Refinements in conceptualization and methodology are suggested for continued exploration of the contribution of neighborhood characteristics to TBI outcomes., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify factors predicting acute hospital discharge disposition after moderate to severe traumatic brain injury (TBI)., Design: Secondary analysis of existing datasets., Setting: Acute care hospitals., Participants: Adults hospitalized with moderate to severe TBI included in 3 large sets of archival data: (1) Centers for Disease Control and Prevention Central Nervous System Injury Surveillance database (n=15,646); (2) the National Trauma Data Bank (n=52,012); and (3) the National Study on the Costs and Outcomes of Trauma (n=1286)., Interventions: None., Main Outcome Measure: Discharge disposition from acute hospitalization to 1 of 3 postacute settings: (1) home, (2) inpatient rehabilitation, or (3) subacute settings, including nursing homes and similar facilities., Results: The Glasgow Coma Scale (GCS) score and length of acute hospital length of stay (LOS) accounted for 35% to 44% of the variance in discharges to home versus not home, while age and sex added from 5% to 8%, and race/ethnicity and hospitalization payment source added another 2% to 5%. When predicting discharge to rehabilitation versus subacute care for those not going home, GCS and LOS accounted for 2% to 4% of the variance, while age and sex added 7% to 31%, and race/ethnicity and payment source added 4% to 5%. Across the datasets, longer LOS, older age, and white race increased the likelihood of not being discharged home; the most consistent predictor of discharge to rehabilitation was younger age., Conclusions: The decision to discharge to home a person with moderate to severe TBI appears to be based primarily on severity-related factors. In contrast, the decision to discharge to rehabilitation rather than to subacute care appears to reflect sociobiologic and socioeconomic factors; however, generalizability of these results is limited by the restricted range of potentially important variables available for analysis., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a new measure, the Participation Assessment With Recombined Tools-Objective (PART-O), based on items from 3 participation instruments., Design: Instrument development based on survey research., Setting: Community., Participants: Adults (N=400) with traumatic brain injury (TBI) 1 to 15 years postinjury, recruited from 8 TBI Model Systems (TBIMS)., Interventions: None., Main Outcome Measure: Community Integration Questionnaire version 2; Participation Objective, Participation Subjective; Craig Handicap Assessment and Reporting Technique; PART-O., Results: Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments, a set of 24 items was developed that covered a broad range of participation content and formed a measure with person separation of 2.47, person reliability of .86, item spread of 4.25 logits, item separation of 11.36, and item reliability of .99. Items were well targeted on the sample with only 1 item misfitting. The PART-O showed expected relationships with measures of impairment, activity limitations, and subjective well-being., Conclusions: The 24-item PART-O is an acceptable measure of objective participation for persons with moderate and severe TBI. It has been adopted as the measure of participation in the TBIMS., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and compare 2 scoring algorithms for a measure of participation, the Participation Assessment with Recombined Tools-Objective (PART-O) based on the assumption that more participation is better versus an alternative that reflects balance in domains of participation., Design: Survey., Setting: Community settings., Participants: Three groups of participants under the age of 65 years were included: (1) persons with spinal cord injury, traumatic brain injury, stroke, and other disorders who are commonly treated in acute rehabilitation settings (n=220), and (2) participants from the general population who did (n=366) or (3) did not (n=284) self-report limitations indicative of a disability who participated in the 2006 Colorado Behavioral Risk Factor Surveillance System (N=870)., Interventions: Not applicable., Main Outcome Measure: PART-O., Results: We developed PART-O subscores using a consensus process and then evaluated them empirically. We combined subscores using 2 contrasting algorithms, one using average scores and the other reflecting the amount of participation and variation in participation across 3 domains. The algorithms for the total scores yielded normal distributions in all 3 samples and were equally sensitive to the impact of disability. While strongly correlated, about 30% of the variance of the 2 total scores was not shared., Conclusions: Two scoring algorithms for the PART-O illustrate contrasting perspectives of the construct of participation. The 2 algorithms may be used in future studies to expand our understanding of the construct of participation., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The model systems (MSs) of care for traumatic brain injury (TBI) is a demonstration program started by the National Institute on Disability and Rehabilitation Research in 1987 to improve care and outcomes for individuals with TBI, from emergency services through life-long follow-up. Over the next 20 years, the program increased in size, and the emphasis shifted from demonstration to research. The focal point of that research is the National Data Base, a longitudinal database including nearly 9000 individuals who were admitted for inpatient acute TBI rehabilitation. In addition to preinjury, injury, acute care, and rehabilitation information, the database includes reports of outcomes at 1, 2, 5, 10, 15, etc, years postinjury. The National Data Base criteria, main contents, and mechanisms used to improve data quantity and quality are described. The MSs' other research is described: local (site-specific), module, and collaborative, with illustrative glimpses of the content. The impact of the TBI MSs program, through dissemination, knowledge translation, training of clinicians and researchers, as well as consulting with policy makers, administrators, clinicians, and researchers is discussed.

Objectives: To assess the suitability of the HIV-Related Fatigue Scale (BFS) [corrected] for assessment of posttraumatic brain injury (post-TBI) fatigue., Design: Analysis of self-report data., Setting: Community., Participants: 183 individuals with TBI in California, and 233 individuals with TBI and a comparison group of 85 persons without brain injury in New York., Interventions: None., Results: Both individuals with TBI and comparison participants reported high levels of fatigue on the Fatigue Severity Scale and the Fatigue Assessment Instrument, which can be scored from the BFS. Factor analysis of 40 BFS items resulted in 5 factors; because factors appeared to be based on both substantive issues and the format and location of the items, a BFS scoring algorithm was not pursued. The other 16 BFS items provided useful information in understanding post-TBI fatigue., Conclusions: The BFS in its current format is not recommended for assessing fatigue as a multidimensional entity after TBI. It may have utility for the 3 widely known fatigue measures that can be derived from it, and it generates information on the circumstances of fatigue.

Background: Participation now replaces community integration or handicap as concepts reflecting the social and interpersonal aspects of disability. If rehabilitation is to adequately measure participation, new measures of participation are needed. To represent the voice of the consumer, such measures should reflect not just "objective," normative aspects, but also subjective ones, tapping the consumer's view of participation., Objectives: To describe the development of and preliminary metrological information on a new measure of participation, Participation Objective, Participation Subjective (POPS)., Methods: A total of 454 community-living individuals with traumatic brain injury (TBI) completed the POPS, as well as measures of quality of life (Life 3), depressive mood (BDI), and TBI symptoms (BISQ). The POPS requires reporting of the share of household activities performed, or the frequency or hours of nonhousehold activities. For each, the subject indicates whether he or she wants to perform more, the same, or less of the activity, and the importance of the activity to well-being. Five subscales and a total scale are calculated, for an objective component (PO), and a subjective component (PS) that reflects importance-weighted satisfaction with activity level., Results: Individuals with mild TBI scored minimally higher than those with moderate-severe TBI on PO subscores, but desired more change on the PS. Test-retest reliability for the PO and the PS and the subscales was from weak (intraclass correlation coefficient 0.28) to adequate (0.89), with PS components having better reliability. The PS component scores had the expected correlations with TBI symptoms, depressed mood, and life satisfaction, among both those with mild injury and those with moderate-severe injury. Injury severity and time since onset were not related to PO or PS scores., Conclusions: The POPS shows promise as a measure of participation. It fills a void in that it reflects both insider and outsider perspectives on participation after TBI.

Objectives: To assess existing knowledge of quality of life (QOL) of people with traumatic brain injury (TBI) and to make recommendations for methodologic and substantive research in this area., Data Sources: Published research on QOL of persons with TBI, identified from databases, ancestry search, and the author's files., Study Selection: Empirical, theoretical, and methodologic articles relevant to 5 areas: QOL as achievements, QOL as subjective well-being (SWB), QOL as utility, QOL experienced, and QOL measurement instruments applicable to TBI or specifically developed for people with this impairment., Data Extraction: Selection of QOL indicators, with focus on TBI versus non-TBI differences., Data Synthesis: Studies of QOL as achievements show that in almost all areas, people with TBI score lower than they did before injury and lower than comparisons groups. There are limited gaps in our knowledge in this area. Research into QOL as SWB shows that after TBI, people typically report, for example, somewhat lower life satisfaction and affect than do comparison groups, and that injury severity is not necessarily a predictor of SWB. There are almost no studies of QOL as utility of life after TBI., Conclusions: Major research recommendations include: exploring the ability of TBI subjects to self-report; determining the salience of domains of life for this group; developing utility instruments that are sensitive to differences in deficits in cognition and other health and life domains; and doing qualitative studies that explore the experience of QOL.

Objective: To examine the factors associated with the remission of insomnia by examining a sample of individuals who had insomnia within the first two years after traumatic brain injury (TBI) and assessing their status at a secondary time point. Design and Methods: Secondary data analysis from a multicenter longitudinal cohort study. A sample of 40 individuals meeting inclusion criteria completed a number of self-report scales measuring sleep/wake characteristics (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Insomnia Severity Index, Sleep Hygiene Index), fatigue and depression (Multidimensional Assessment of Fatigue, Patient Health Questionnaire-9), and community participation (Participation Assessment with Recombined Tools-Objective). One cohort was followed at 1 and 2 years post-injury (n = 19) while a second cohort was followed at 2 and 5 years post-injury (n = 21). Results: Remission of insomnia was noted in 60% of the sample. Those with persistent insomnia had significantly higher levels of fatigue and depression at their final follow-up and poorer sleep hygiene across both follow-up time-points. A trend toward reduced community participation among those with persistent insomnia was also found. Conclusion: Individuals with persistent post-TBI insomnia had poorer psychosocial outcomes. The chronicity of post-TBI insomnia may be associated with sleep-related behaviors that serve as perpetuating factors. [ABSTRACT FROM AUTHOR]

To use causal inference methods to determine if receipt of a greater proportion of inpatient rehabilitation treatment focused on higher level functions, for example, executive functions, ambulating over uneven surfaces (advanced therapy [AdvTx]), results in better rehabilitation outcomes. A cohort study using propensity score methods applied to the traumatic brain injury practice-based evidence (TBI-PBE) database, a database consisting of multisite, prospective, longitudinal observational data. Acute inpatient rehabilitation facilities. Patients enrolled in the TBI-PBE study (N=1843), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, receiving their first inpatient rehabilitation facility admission to 1 of 9 sites in the United States, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. Not applicable. Participation Assessment with Recombined Tools-Objective-17, FIM motor and cognitive scores, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Controlling for measured potential confounders, increasing the percentage of AdvTx during inpatient TBI rehabilitation was found to be associated with better community participation, functional independence, life satisfaction, and decreased likelihood of depression during the year after discharge from inpatient rehabilitation. Participants who began rehabilitation with greater disability experienced larger gains on some outcomes than those who began rehabilitation with more intact abilities. Increasing the proportion of treatment targeting higher level functions appears to have no detrimental and a small, beneficial effect on outcome. Caution should be exercised when inferring causality given that a large number of potential confounders could not be completely controlled with propensity score methods. Further, the extent to which unmeasured confounders influenced the findings is not known and could be of particular concern due to the potential for the patient's recovery trajectory to influence therapists' decisions to provide a greater amount of AdvTx. [ABSTRACT FROM AUTHOR]

The Traumatic Brain InjuryModel Systems Center (TBIMSC) program was established by the National Institute on Disability, Independent Living, and Rehabilitation Research in 1987, with the goal of conducting research to improve the care and outcomes for individuals with moderate-to-severe traumatic brain injury (TBI). This article provides an update on TBIMSC research program activities since 2010 when a similar article was published. It includes (1) discussion of TBIMSC program management and infrastructure; (2) detail on the management, data quality, access, use, and knowledge translation of the TBIMSC National Database, with more than 16 000 participants with follow-up out to 25 years postinjury to date; (3) an overview of the TBIMSC site-specific studies and collaborative module research; (4) highlights of several collaborative initiatives between the TBIMSCs and other federal, advocacy, and research stakeholders; (5) an overview of the vast knowledge translation occurring through the TBIMSCprogram; and (6) discussion of issues that impact on the data collection methods for and contents of the TBIMSC National Database. On the occasion of the 30th anniversary of the TBIMSC program, this article highlights many of the accomplishments of this well-established, multicenter TBI research consortium. [ABSTRACT FROM AUTHOR]

Post-traumatic brain injury fatigue (PTBIF) is a major problem in the years after traumatic brain injury (TBI), yet little is known about its persistence and resolution. The objective of the study was to identify factors related to PTBIF remission and resolution. TBI Model System registrants at five centres participated in interviews at either one and two years post-injury (Y1-2 Cohort), or two and five years post-injury (Y2-5 Cohort). Characteristics of participants with PTBIF remission were compared to those with PTBIF persistence. Variables studied included the presence of and changes in disability, sleep dysfunction, mood, and community participation. The Functional Independence Measure did not differ significantly between groups or over time. In the Y1-2 Cohort the Fatigue Resolved group scored significantly better on the Disability Rating Scale and Pittsburgh Sleep Quality Index. In the Y2-5 Cohort the Fatigue Resolved group scored significantly higher on a measure of community participation. It was concluded that fewer than half of the sample in each cohort experienced a remission of PTBIF between time points. Persistence of PTBIF 1–2 years post-injury is associated with disability, sleep disturbance, and depression while persistence of fatigue beyond 2 years post-injury appears to be related to participation level, underscoring the potential impact of effective surveillance, assessment, and treatment of this condition in optimising life after TBI. Differences in fatigue progression may point to the presence of different types of PTBIF. [ABSTRACT FROM PUBLISHER]

Abstract: Objective: To identify baseline participant variables in the domains of demographics, medical/psychosocial history, injury characteristics, and postinjury functional status associated with longitudinal follow-up completeness in persons with traumatic brain injury (TBI) using the TBI Model Systems (TBIMS) National Database (NDB). Design: Exhaustive chi-square automatic interaction detection was used to identify factors that classified participants according to level of follow-up completeness. Setting: Retrospective analysis of a multi-center longitudinal database. Participants: Individuals (N=8249) enrolled in the TBIMS NDB between 1989 and 2009 who were eligible for at least the first (year 1) follow-up up to the fifth (year 15) follow-up. Interventions: None. Main Outcome Measures: Follow-up completeness as defined by 6 different longitudinal response patterns (LRPs): completing all follow-ups, wave nonresponse, dropping out, completing no follow-ups without formally withdrawing, formally withdrawing before completing any follow-ups, and formally withdrawing after completing some follow-ups. Results: Completing all follow-ups was associated with higher levels of education, living with parents or others, and having acute care payer data entered in the NDB. Subgroups more vulnerable to loss to follow-up (LTFU) included those with less education, racial/ethnic minority backgrounds, those with better motor functioning on rehabilitation discharge, and those for whom baseline data on education, employment, and acute care payer were not collected. No subgroups were found to be more likely to have the LRPs of dropping out or formal withdrawal. Conclusions: These data identify subgroups in which retention strategies beyond those most commonly used might reduce LTFU in longitudinal studies of persons with TBI, such as the TBIMS, and suggest future investigations into factors associated with missing baseline data. [Copyright &y& Elsevier]

Abstract: Graham JE, Radice-Neumann DM, Reistetter TA, Hammond FM, Dijkers M, Granger CV. Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury. Objective: To assess the influence of sex and age on inpatient rehabilitation outcomes in a large national sample of older adults with traumatic brain injury (TBI). Design: Prospective case series. Setting: Eight hundred forty-eight inpatient rehabilitation facilities that subscribe to the Uniform Data System for Medical Rehabilitation. Participants: Patients (n=18,413) age 65 years and older admitted for inpatient rehabilitation after TBI from 2005 through 2007. Interventions: None. Main Outcome Measures: Rehabilitation length of stay, discharge FIM motor and cognitive ratings, discharge setting, and scheduled home health services at discharge. Results: Mean age ± SD of the sample was 79±7 years, and 47% were women. In multivariable models, higher age was associated with shorter lengths of stay (P<.001), lower discharge FIM motor and cognitive ratings (P<.001), and greater odds of home health services at discharge (P<.001). Women demonstrated shorter lengths of stay (P=.006) and greater odds of being scheduled for home health services at discharge (P<.001) than men. The sex-by-age interaction term was not significant in any outcome model. Sex differences and trends were consistent across the entire age range of the sample. Conclusions: Sex and age patterns in rehabilitation outcomes among older adults with TBI varied by outcome. The current findings related to rehabilitation length of stay may be helpful for facility-level resource planning. Additional studies are warranted to identify the factors associated with returning to home and to assess the long-term benefits of combined inpatient rehabilitation and home health services for older adults with TBI. [Copyright &y& Elsevier]

Objective: To assess the suitability of the Barroso Fatigue Scale (BFS) for assessment of posttraumatic brain injury (post-TBI) fatigue. Design: Analysis of self-report data. Setting: Community. Participants: 183 individuals with TBI in California, and 233 individuals with TBI and a comparison group of 85 persons without brain injury in New York. Interventions: None. Results: Both individuals with TBI and comparison participants reported high levels of fatigue on the Fatigue Severity Scale and the Fatigue Assessment Instrument, which can be scored from the BFS. Factor analysis of 40 BFS items resulted in 5 factors; because factors appeared to be based on both substantive issues and the format and location of the items, a BFS scoring algorithm was not pursued. The other 16 BFS items provided useful information in understanding post-TBI fatigue. Conclusions: The BFS in its current format is not recommended for assessing fatigue as a multidimensional entity after TBI. It may have utility for the 3 widely known fatigue measures that can be derived from it, and it generates information on the circumstances of fatigue. [ABSTRACT FROM AUTHOR]