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Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often co-occurs with psychological and medical conditions such as posttraumatic stress disorder (PTSD) and sleep apnea. We aimed to examine if sleep apnea is associated with the presence and severity of PTSD in V/SM with TBI of all severities.The study examined participants at varying times since their TBI (Almost 32% of the sample stated they had been diagnosed with sleep apnea. In those reporting sleep apnea, 32% also had probable PTSD; 19% of those without sleep apnea had probable PTSD. The regression demonstrated sleep apnea was significantly associated with PTSD symptom severity (TBI, PTSD, and sleep apnea are often comorbid in V/SM. We expand the literature by demonstrating that sleep apnea was associated with PTSD severity. A multipronged approach to TBI rehabilitation that addresses sleep and psychological distress is recommended for enhancing health outcomes in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective: To examine the impact of bright white light (BWL) exposure on sleep quality in persons with recent traumatic brain injury (TBI).Design: Randomized, controlled device-sham studySetting: 3...

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

BACKGROUND: Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations. METHODS: We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated. RESULTS: Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79. CONCLUSION: The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries. LEVEL OF EVIDENCE: Epidemiologic/Therapeutic study, level IV.

OBJECTIVES The primary outcome of this study was to assess the efficacy and safety of preventive treatment with amitriptyline on headache frequency and severity after mild traumatic brain injury (mTBI). BACKGROUND Despite the fact that headache is the most common and persistent physical symptom after TBI, there has been little research on the longitudinal course or pharmacologic treatment of this disorder. Of those who have headache after injury, about 60% continue to complain of headache at 3 months post injury, with higher levels of disability than those without headache. There have been no prospective, randomized, controlled trials of a pharmacologic agent for headache after TBI. Additionally, a brain-injured population may be more susceptible to side effects of medication. DESIGN This is a single-center phase II trial of amitriptyline to prevent persistent headache after an mTBI. Medication dose was gradually increased from 10 to 50 mg daily. RESULTS Fifty participants were enrolled and 33 who completed the 90-day assessment were included in the final analysis. In order to detect a possible cognitive impact of the study drug, 24 participants were randomly assigned to start amitriptyline immediately after study enrollment and 26 were assigned to start 30 days after enrollment. Forty-nine percent (18/37) of those assigned to take medication took none throughout the study period, with less compliance in younger participants with mean ages of 32.7 in those who did not take any medication, 33.4 who were less than 80% compliant, and 42.3 who were compliant (P = .013). Compliance in keeping a daily headache diary was low, with 29/50 participants (58%) meeting daily entry completion, and only 10 participants maintaining 100% diary completion. No differences were found between those who started medication immediately vs at day 30 in headache frequency or severity. CONCLUSIONS While headache is the most common symptom following mTBI, current evidence does not support a specific treatment. No differences were noted in headache frequency compared to our prior study. However, the current sample had significantly lower headache severity (15% vs 36% with pain rating of 6 or above, P = .015) compared to our prior study. Our current study was not able to determine whether there is any benefit for the use of amitriptyline as a headache preventive because of difficulty with study recruitment and compliance. The challenges with recruitment and retention in the mTBI population were instructive, and future research in this area will need to identify strategies to improve recruitment, diary compliance, and medication adherence in this population.

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

Objectives To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications. Setting Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI). Participants A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites. Design Cross-sectional, secondary analyses. Main measures The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index. Results After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids. Conclusion Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

OBJECTIVE To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). DATA SOURCES The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. RESULTS Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. CONCLUSIONS Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

Background Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. Objective The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. Research design Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. Results Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. Conclusion These lessons can help guide future pragmatic studies of care transitions.

Research Objectives To identify treatments utilized by Service Members and Veterans (SMVs) with TBI and chronic pain and characterize access barriers and facilitators to non-pharmacologic treatments. Design A secondary data analysis of SMV with TBI interview data guided by a biopsychosocial model of pain management1-3 and framework for accessing healthcare services4. Setting Five geographically diverse VA Polytrauma Rehabilitation Centers (PRC) within the Department of Veterans Affairs. Participants The secondary data analysis includes a sample of 55 SMVs with chronic TBI (>2 years) who were enrolled in VA TBI Model Systems. Half the sample had severe TBI (56%) with a mean age of 43 at time of injury, were male (93%), and married (51%). Interventions N/A. Main Outcome Measures Facilitators and barriers to accessing non-pharmacologic chronic pain treatment. Results Thematic analysis revealed that chronic pain and/or headache was a common rehabilitation need. The use of polypharmacy (including opioid use) was a common theme for those reporting chronic pain concerns. Facilitators to accessing treatment (including non-pharmacological treatments) for chronic pain included the ability to use the VA Choice Program to access community care and family or other social support to advocate for treatment. The primary barriers to accessing care for chronic pain included having insufficient information about alternative treatment options. Conclusions Despite VA/DoD clinical practice guidelines advising against using opioids in persons with documented TBI, polypharmacy emerged as a theme in this study cohort. Findings highlight facilitators and barriers to alternative evidence-based treatments with implications for practice and policy. Author(s) Disclosures None.

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p 0.001) and slower processing speed (r = 0.23, p 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p 0.001) and PTSD symptoms (r = 0.44, p 0.001), and slower processing speed (r = -0.22, p 0.001).The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Objective To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models. Design Cross-sectional, 1-5 days of data collection. Setting Community-based data collection. Participants Adults with chronic (>1 year), motor incomplete SCI (N=27). Interventions Not applicable. Main Outcome Measures Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results. Results The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models. Conclusions The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

We assessed safety and potential efficacy of a chamomile gel compared with urea cream to prevent acute radiation dermatitis in head and neck cancer patients. We assessed safety and potential efficacy of the chamomile gel in escalating concentrations of 2.50%, 5.00% and 8.35% of chamomile. Concentration of 8.35% was chosen for a randomized trial comparing chamomile gel (8.35%) with urea cream (n = 24 per group), for potential efficacy to delay or prevent radiation dermatitis in these patients. Preliminary results demonstrate a delayed onset of dermatitis, with onset of Grade 2 dermatitis at 5.1 (1.3) weeks in the chamomile group and 4.5 (1.3) weeks in the urea group (effect size of 0.46). Itching, burning and hyperpigmentation were more frequently reported in the urea group. Results indicates a potential efficacy of the chamomile gel. Further studies are needed to confirm the effect of the chamomile gel in reducing or delaying the occurrence of radiation dermatitis.

For patients surviving serious traumatic brain injury (TBI), families and other stakeholders often desire information on long-term functional prognosis, but accurate and easy-to-use clinical tools are lacking. We aimed to build utilitarian decision trees from commonly collected clinical variables to predict Glasgow Outcome Scale (GOS) functional levels at 1, 2, and 5 years after moderate-to-severe closed TBI. Flexible classification tree statistical modeling was used on prospectively collected data from the TBI-Model Systems (TBIMS) inception cohort study. Enrollments occurred at 17 designated, or previously designated, TBIMS inpatient rehabilitation facilities. Analysis included all participants with nonpenetrating TBI injured between January 1997 and January 2017. Sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5) after cross-sectional exclusions (death, vegetative state, insufficient post-injury time, and unavailable outcome). In our final models, post-traumatic amnesia (PTA) duration consistently dominated branching hierarchy and was the lone injury characteristic significantly contributing to GOS predictability. Lower-order variables that added predictability were age, pre-morbid education, productivity, and occupational category. Generally, patient outcomes improved with shorter PTA, younger age, greater pre-morbid productivity, and higher pre-morbid vocational or educational achievement. Across all prognostic groups, the best and worst good recovery rates were 65.7% and 10.9%, respectively, and the best and worst severe disability rates were 3.9% and 64.1%. Predictability in test data sets ranged from C-statistic of 0.691 (year-1; confidence interval [CI], 0.675, 0.711) to 0.731 (year-2; CI, 0.724, 0.738). In conclusion, we developed a clinically useful tool to provide prognostic information on long-term functional outcomes for adult survivors of moderate and severe closed TBI. Predictive accuracy for GOS level was demonstrated in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant.

To gather information about brain injury (BI) survivors' long-term healthcare needs, quality, barriers and facilitators.Qualitative content analysis of data gathered in focus groups using semi-structured interviews.Forty-four community-dwelling adults participated at two clinical research centres in Seattle, Washington and New York, New York. Participants were asked open-ended questions about their experiences with healthcare in the community with regard to care needs, utilization, access, barriers and facilitators to health management.Central themes emerged across three categories: 1) barriers to healthcare access/utilization, 2) facilitators to healthcare access/utilization, and 3) suggestions for improving healthcare after BI. The importance of communication as both a facilitator and barrier to care was mentioned by most participants. Compensatory strategies and external tools were identified as key facilitators of medical self-management. Finally, improving clinicians' knowledge about BI emerged as a potential solution to address health needs of individuals with chronic BI.Additional efforts need to be made to improve access to appropriate healthcare and increase the ability for individuals to successfully navigate the healthcare system. Findings suggest several specific, low-cost modifications to healthcare delivery and strategies for improving medical self-management that can maximize long-term health maintenance for BI survivors.

Introduction Obstructive Sleep Apnea (OSA) is prevalent after moderate to severe traumatic brain injury (TBI) and may diminish recovery when left untreated. Despite the demonstrated importance of treating OSA following TBI, assessment for OSA during or soon after inpatient rehabilitation for TBI is limited. Little is known about barriers to implementing OSA screening and early diagnosis during inpatient rehabilitation thus hindering the translation of evidence-based OSA assessment procedures into clinical practice and potentially delaying necessary OSA treatment. The current analysis explored facilitators and barriers to implementing OSA screening tools in an inpatient rehabilitation setting from the perspectives of end user stakeholders. Methods Patients, families, industry, clinical providers and administrators participated in a two-day meeting following completion of a diagnostic clinical trial of OSA screening and diagnostic tools during inpatient rehabilitation. Stakeholders were provided with open ended questions generated by study investigators and given the opportunity to respond on paper or a “graffiti wall” (i.e., white board). Example questions include “What are the greatest needs of the healthcare system related to sleep apnea and TBI?” and “What are the key things we need to consider to move results into real-world practice?” Qualitative content analyses using a rapid matrix approach were conducted from stakeholder feedback obtained during the two-day meeting, which included a guided review of emerging OSA research and discussion of potential implementation barriers of OSA assessment during inpatient rehabilitation. Results Improved screening and treatment practices for OSA were the greatest needs identified. To meet these needs, stakeholders identified the importance of improving patient, family, and staff understanding of OSA (e.g., health literacy) and other sleep disorders through education; inpatient rehabilitation access to resources (technology; sleep providers); and reimbursement for additional inpatient procedures. Conclusion Although treatment of OSA is crucial for recovery during inpatient rehabilitation following TBI, barriers to earlier recognition, diagnosis, and treatment of OSA exists across several different domains, including education, resources, and funding policies. Findings support future implementation efforts to translate evidence-based care into practice to improve patient outcomes. Support (if any) PCORI-NCT03033901

Research Objectives To identify differences sleep related respiration between those receiving and not receiving opioid medications. Design Cross-sectional, secondary analyses. Setting Acute inpatient rehabilitation for moderate to severe TBI. Participants 248 consecutive admissions who underwent level-1 polysomnography. Interventions Receipt of opioid medications on the day of polysomnography (PSG). Main Outcome Measures PSG including respiratory measures: oxygen saturation, central apneas events per hour, obstructive apneas and hypopnea events per hour, and total apnea-hypopnea index (AHI). Results After adjustment for number of prescribed medications, those receiving opioids on day of PSG experienced increased frequency of central sleep apnea events and higher frequency of obstructive sleep apnea events. Compared to those who did not, receiving opioids was associated with lower oxygen saturation nadir during and a greater number of oxygen desaturations across. Greater total AHI was observed for those receiving opioids. Conclusions Opioid use early after TBI appears to impact important sleep parameters and sleep related respiration that may influence recovery. Further investigation is needed to understand the impact of opioid medications, alone or in combination with other medications, on functional outcomes both early after TBI and in the chronic phase to develop recommendations on how and when to use these medications given their usage in managing pain after injury. Author(s) Disclosures Research reported in this article was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1511-33005). This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ13-C-0015; HT0014-19-C-0004) from the Defense Health Agency TBI Center of Excellence and National Institute on Disability, Independent Living, and Rehabilitation Research (University of Texas Southwestern Medical Center, 90DPTB0013-01-03; Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 90DRTB0002; Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine, 90DPTB0008). The TBI Model Systems is a funded collaboration between the Department of Veterans Affairs and the Department of Health and Human Services: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Clinicaltrial.gov Registration Number: NCT03033901.

Objective To describe the rates and causes for rehospitalization over 10 years after moderate-severe traumatic brain injury (TBI), and to characterize longitudinal trajectories of the probability of rehospitalization using generalized linear mixed models and individual growth curve models conditioned on factors that help explain individual variability in rehospitalization risk over time. Design Secondary analysis of data from a multicenter longitudinal cohort study. Setting Acute inpatient rehabilitation facilities and community follow-up. Participants Individuals 16 years and older with a primary diagnosis of TBI. Main outcome measures Rehospitalization (and reason for rehospitalization) as reported by participants or proxy during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. Results The greatest number of rehospitalizations occurred in the first year postinjury (27.8% of the sample), and the rates of rehospitalization remained largely stable (22.1%-23.4%) at 2, 5, and 10 years. Reasons for rehospitalization varied over time: Orthopedic and reconstructive surgery rehospitalizations were most common in year 1, whereas general health maintenance was most common by year 2 with rates increasing at each follow-up. Longitudinal models indicate that multiple demographic and injury-related factors are associated with the probability of rehospitalization over time. Conclusions These findings can inform the content and timing of interventions to improve health and longevity after TBI.

Introduction Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions. Methods This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47). Results Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

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

Background Headache after traumatic brain injury (TBI) is frequent and persistent over the first year after injury. Providers may need to focus on different symptom presentations depending on their patient's TBI severity. Objective We evaluated headache symptoms in patients with moderate-to-severe TBI compared to patients with mild TBI and examined our data from two perspectives: (1) from providers who treat individuals after TBI and manage multiple postinjury symptoms including headache, and (2) from headache specialists who see individuals after TBI to manage headache. Design Prospective enrollment of individuals after TBI with telephone follow-up at 1-year postinjury. Setting Enrollment from hospital and then community followup. Participants Three hundred forty-six individuals with moderate-to-severe TBI were enrolled during acute inpatient rehabilitation across seven TBI Model System Centers. One hundred eighty-nine individuals with mild TBI were enrolled within 1 week of injury at a single center. Intervention None. Main outcome measurements Headache frequency, headache type, pain intensity, Headache Impact Test-6 (HIT-6), and depressive symptoms measured 1 year after injury. Results Headache prevalence is high in both TBI groups. TBI providers are more likely to evaluate and treat headache from individuals sustaining a mild TBI versus moderate-to-severe TBI. Patients with mild TBI are most likely to report tension-type headache followed by migraine-type headache. The migraine-type headache has higher impact (HIT-6) and greater pain intensity. Headache specialists may encounter patients with moderate-to-severe TBI who report more frequent headache and higher average pain scores compared to patients with mild TBI. The severity of TBI was unrelated to depressive symptoms 1 year after injury, but patients with headache were significantly more likely to have higher scores. Conclusions TBI providers versus headache specialists should be aware of differences in patient symptom presentation to their respective clinics. Ongoing assessment of headache and depression over time is important following TBI of any severity.

Background OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI. Research Question This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI. Study Design and Methods This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days). Results Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764). Interpretation Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

OBJECTIVE: To examine the predictive ability of depression when considering long-term employment outcomes for individuals with moderate-to-severe TBI, after controlling for key pre-injury and injury-related variables. DESIGN: Secondary data analysis. SETTING: Community follow-up after discharge from an inpatient rehabilitation center. PARTICIPANTS: Individuals between 18 and 60 years-old with moderate-to-severe TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status. RESULTS: The prevalence of employment at 2 and 5 years post-injury was 40.3% and 44.5%, respectively. Individuals identified at depressed at 1 year were less likely to be employed at 2 years post-injury (OR=1.77; 95% CI: 1.38, 2.27; p

Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Due to challenges that include inconsistent access to follow-up care, persons with TBI being discharged from inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor reintegration into the community, family stress, and other unfavorable outcomes resulting from unmet needs. In a six-center randomized pragmatic comparative effectiveness study, the BRITE trial (Brain Injury Rehabilitation: Improving the Transition Experience, ClinicalTrials.gov NCT03422276 ), we compare the effectiveness of two existing methods for transition from IRF to community living or long-term nursing care. The Rehabilitation Discharge Plan (RDP) includes patient/family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference, for 6 months. Nine hundred patients will be randomized (1:1) to RDP or RTP, with caregivers also invited to participate and contribute caregiver-reported outcomes. Extensive stakeholder input, including active participation of persons with TBI and their families, has informed all aspects of trial design and implementation planning. We hypothesize that RTP will result in better patient- and caregiver-reported outcomes (societal participation, quality of life, caregiver well-being) and more efficient use of healthcare resources at 6-months (primary outcome) and 12-months post-discharge, compared to RDP alone. Planned analyses will explore which participants benefit most from each transition model. With few exclusion criteria and other pragmatic features, the findings of this trial are expected to have a broad impact on improving transitions from inpatient TBI rehabilitation. Trial registration ClinicalTrials.gov identifier NCT03422276

Objectives To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes. Design Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI. Setting Inpatient rehabilitation unit. Participants From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed. Interventions Not applicable. Main Outcome Measure Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI. Results Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%–93%), a specificity of 51% (95% confidence interval, 39%–64%), and a Youden Index of 0.3 (95% confidence interval, 0.2–0.5). Compared with those without TBI, those with chart review–determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes. Conclusions Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Objective To examine the role of residential neighborhood characteristics in accounting for race disparities in participation among a large sample of community-living adults with chronic spinal cord injury (SCI). Design Secondary analysis of cross-sectional survey data from the national Spinal Cord Injury Model Systems (SCIMS) database linked with national survey and spatial data. Setting SCIMS database participants enrolled at 10 collaborating centers active in follow-up between 2000 and 2014. Participants The sample consisted of persons with SCI (N=6892) in 5441 Census tracts from 50 states and the District of Columbia. Intervention Not applicable. Main Outcome Measure The Craig Handicap Assessment and Reporting Technique was used to measure full participation across 4 domains: physical independence, mobility, occupation, and social integration. Results Racial minority groups had lower odds of reporting full participation relative to whites across all domains, suggesting that blacks and Hispanics are at risk for poorer community reintegration after SCI. Neighborhood characteristics, notably differences in socioeconomic advantage, reduced race group differences in the odds of full occupational and social integration, suggesting that the race disparities in community reintegration after SCI are partially attributable to variation in the economic characteristics of the places where people live. Conclusions This investigation suggests that addressing disadvantage at the neighborhood level may modify gaps in community participation after medical rehabilitation and provides further support for the role of the environment in the experience of disability.

Sleep problems are common in spinal cord injury (SCI) and multiple sclerosis (MS). However, the degree to which sleep problems differ between these distinct clinical populations has not been evaluated. In this study, we examined self-reported sleep problems in individuals with SCI and those with MS, and compared these clinical groups on the Medical Outcomes Study Sleep Scale (MOS-SS).Participants were 1,677 individuals (SCI = 581; MS = 1,096) enrolled in longitudinal study of self-reported health outcomes in SCI and MS. Univariate and multivariate analysis of covariance examined group differences on global sleep problems and domain-specific subscales of the MOS-SS.Individuals with SCI reported an average of 30 fewer min of sleep per night (Sleep Quantity subscale) and significantly greater difficulty initiating and maintaining sleep (Sleep Disturbance subscale) compared to individuals with MS. However, groups did not differ on global sleep problems (Sleep Problems Index 9).Although global sleep problems are more common in SCI and MS than in the general population, these groups exhibit differing sleep problem profiles, and thus may require unique treatment approaches to address the specific domains of sleep affected. For individuals with SCI, an additional focus on increasing sleep quantity and reducing sleep disruptions may be warranted.

To determine the number and type of longitudinal depression trajectories during the first year after spinal cord injury (SCI) and to identify baseline predictors of these trajectories.Cohort study.Rehabilitation and postacute community settings.Of 168 consecutive admissions to inpatient rehabilitation for acute SCI, 141 (115 men, 26 women) patients were enrolled in a randomized controlled trial telephone follow-up intervention, which showed no outcome differences, and completed assessments on at least 2 of the 4 follow-up occasions (3, 6, 9, and 12 months after SCI). Participants were on average 41 years old, most were non-Hispanic (96%) and white (86%), and 61.7% had tetraplegia.Data were drawn from the ineffective randomized controlled trial.Patient Health Questionnaire-9 (PHQ-9).Unconditional linear latent class growth analysis models of PHQ-9 total scores revealed an optimal 3-class solution: stable low depression (63.8%), mild to moderate depression (29.1%), and persistent moderate to severe depression (7.1%). Preinjury mental health history and baseline pain, quality of life, and grief predicted class membership.The modal response to SCI was stable low depression, whereas persistent moderate to severe depression primarily represented a continuation or relapse of preinjury depression. This line of research has the potential to improve identification of subgroups destined for poor outcomes and to inform early intervention studies.

Background Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation. Objective This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure. Methods Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG). Results To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea. Conclusions Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

STUDY DESIGN: Secondary analysis of data from a prospective clinical trial of telephone counseling. OBJECTIVES: To describe changes in bladder management and development of bladder-related complications in the first year after discharge from inpatient spinal cord injury (SCI) rehabilitation. To determine whether urinary tract infection (UTI) is associated with bladder management technique or severity of SCI during this time period. SETTING: One SCI Model System center. METHODS: Post hoc analysis of bladder-specific responses to a phone intervention meant to reduce secondary complications of paralysis in adults (n = 169) over the first year after discharge from initial inpatient rehabilitation (IR). RESULTS: Bladder management was associated with injury level during and immediately after inpatient rehabilitation, and with American Spinal Injury Association (ASIA) Impairment Scale (AIS) score over the entire year. During one year of follow-up, 19% of patients changed bladder management techniques. Among participants performing intermittent catheterization (IC), 20% had urinary incontinence weekly or more frequently. The cumulative incidence of UTI was 71% by the end of the study, and between 27 and 46% of subjects reported UTIs during each 3-month period. Subjects with spontaneous voiding reported significantly fewer UTIs than those using IC or indwelling catheterization (IDC), but there was no significant difference in UTIs between IC and IDC. CONCLUSION: During the first year following discharge, approximately one in five patients changed the bladder management technique and urinary incontinence occurred in a substantial proportion of those performing IC. These findings suggest a need for more frequent monitoring of bladder changes and complications over the first year after IR.

Objective To build decision tree prediction models for long-term employment outcomes of individuals after moderate to severe closed traumatic brain injury (TBI) and assess model accuracy in an independent sample. Setting TBI Model Systems Centers. Participants TBI Model Systems National Database participants injured between January 1997 and January 2017 with moderate to severe closed TBI. Sample sizes were 7867 (year 1 postinjury), 6783 (year 2 postinjury), and 4927 (year 5 postinjury). Design Cross-sectional analyses using flexible classification tree methodology and validation using an independent subset of TBI Model Systems National Database participants. Main measures Competitive employment at 1, 2, and 5 years postinjury. Results In the final employment prediction models, posttraumatic amnesia duration was the most important predictor of employment in each outcome year. Additional variables consistently contributing were age, preinjury education, productivity, and occupational category. Generally, individuals spending fewer days in posttraumatic amnesia, who were competitively employed preinjury, and more highly educated had better outcomes. Predictability in test data sets ranged from a C-statistic of 0.72 (year 5; confidence interval: 0.68-0.76) to 0.77 (year 1; confidence interval: 0.74-0.80). Conclusion An easy-to-use decision tree tool was created to provide prognostic information on long-term competitive employment outcomes in individuals with moderate to severe closed TBI. Length of posttraumatic amnesia, a clinical marker of injury severity, and preinjury education and employment status were the most important predictors.

Background and objectives Chronic pain is a highly prevalent and potentially disabling condition in Veterans who have had a traumatic brain injury (TBI) and access to non-pharmacological pain treatments such as cognitive behavioral therapy is limited and variable. The purpose of this randomized controlled trial (RCT) is to evaluate the efficacy of a telephone-delivered cognitive behavioral therapy (T-CBT) for pain in Veterans with a history of TBI. Methods Veterans with a history of TBI and chronic pain of at least six months duration (N = 160) will be randomized to either T-CBT or a telephone-delivered pain psychoeducational active control condition (T-Ed). The eight-week T-CBT intervention builds on other efficacious CBT interventions for chronic pain in the general population but is novel in that it is conducted via telephone and adapted for Veterans with a history of TBI. Outcome variables will be collected pre, mid-, and post-treatment, and 6 months following randomization (follow-up). Projected outcomes In addition to evaluating the effects of the interventions on pain intensity (primary outcome), this study will determine their effects on pain interference, sleep, depression, and life satisfaction. We will also examine potential moderators of treatment outcomes such as cognition, PTSD, and alcohol and drug use. This non-pharmacologic one-on-one therapeutic intervention has the potential to reduce pain and pain-related dysfunction, improve access to care, and reduce barriers associated with geography, finances, and stigma, without the negative effects on physical and cognitive performance and potential for addiction as seen with some pharmacologic treatments for pain. This trial is registered at ClinicalTrials.gov , protocol NCT01768650

Epidemiological studies suggest that a single moderate-to-severe traumatic brain injury (TBI) is associated with an increased risk of neurodegenerative disease, including Alzheimer's disease (AD) and Parkinson's disease (PD). Histopathological studies describe complex neurodegenerative pathologies in individuals exposed to single moderate-to-severe TBI or repetitive mild TBI, including chronic traumatic encephalopathy (CTE). However, the clinicopathological links between TBI and post-traumatic neurodegenerative diseases such as AD, PD, and CTE remain poorly understood. Here, we describe the methodology of the Late Effects of TBI (LETBI) study, whose goals are to characterize chronic post-traumatic neuropathology and to identify in vivo biomarkers of post-traumatic neurodegeneration. LETBI participants undergo extensive clinical evaluation using National Institutes of Health TBI Common Data Elements, proteomic and genomic analysis, structural and functional magnetic resonance imaging (MRI), and prospective consent for brain donation. Selected brain specimens undergo ultra-high resolution ex vivo MRI and histopathological evaluation including whole–mount analysis. Co-registration of ex vivo and in vivo MRI data enables identification of ex vivo lesions that were present during life. In vivo signatures of postmortem pathology are then correlated with cognitive and behavioral data to characterize the clinical phenotype(s) associated with pathological brain lesions. We illustrate the study methods and demonstrate proof of concept for this approach by reporting results from the first LETBI participant, who despite the presence of multiple in vivo and ex vivo pathoanatomic lesions had normal cognition and was functionally independent until her mid-80s. The LETBI project represents a multidisciplinary effort to characterize post-traumatic neuropathology and identify in vivo signatures of postmortem pathology in a prospective study.

Background In patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections. Objectives The objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC. Methods One hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip. Results Of 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes. Conclusions Our preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.

OBJECTIVE: To examine headache and depression over time in individuals who sustained mild traumatic brain injury (mTBI). Prevalence of headache and depression early after mTBI and at 1 year postinjury as well as the relationship between the two are evaluated. BACKGROUND: Headache is the most common physical symptom and depression is among the most common psychiatric diagnosis after traumatic brain injury regardless of severity. Headache and depression have been found to be two independent factors related to poor outcome after mTBI, yet there appears to be a paucity of research exploring the comorbidity of these two conditions after injury. METHOD/DESIGN: Longitudinal survey design over 1 year of 212 participants with mTBI who were admitted to a Level 1 trauma center for observation or other system injuries. Depression was based on a score ≥10 on the Patient Health Questionnaire-9. Headache was based on participant report of new or worse-than-preinjury headache since hospitalization (baseline) or within the previous 3 months at 1 year postinjury. RESULTS: The prevalence of headache and depression at baseline was 64% (135/212) and 15% (31/212), respectively. The prevalence of headache and depression at 1 year was 68% (127/187) and 27% (50/187), respectively. The co-occurrence of headache and depression increased from 11% (23/212) at baseline to 25% (46/187) at 1 year. At 1 year, the risk ratio of individuals who had headache to be depressed was 5.43 (95% CI 2.05-14.40) compared to those without headache (P CONCLUSIONS: While prevalence of headache is consistently high over the first year after injury, rate of depression increased over the first year for those who were followed. Given the high rate of comorbidity, those with headache may develop depression over time. Evaluation for possible depression in those with headache after mTBI should be conducted to address both conditions over the year following injury. Language: en

To describe the initial benefits of a structured group exercise program on exercise frequency and intensity, perceived health, pain, mood, and television watching habits.Pre-test/post-test.Eighty-nine persons with SCI participated voluntarily in a no-cost, twice weekly physical therapy group exercise class over 3 months. Forty-five persons completed pre- and post-participation interviews on exercise frequency and intensity, perceived health, pain, mood, sleep, and television watching habits.Mean participant age of the respondents was 43.82 years. 49% had AIS C or D injuries, 24% had AIS A,B paraplegia, 9% had AIS A,B C1-C4 and 18% had AIS A,B C5-C8. 75.6% of participants were male and 84.4% had a traumatic etiology as the cause of their SCI. There was a significant improvement in days of strenuous and moderate exercise as well as health state. There was an average decrease in pain scores, depression scores, number of hours spent watching television, and days/week of mild exercise.Participation in structured, small group exercise as a component of a wellness program after SCI shows promise for improving regular exercise participation and health state, but benefits may also occur across other areas of health and function including mood, pain, and hours spent watching television. Further follow-up is needed to determine whether improvements can be maintained after program completion and across all neurological levels.

To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI).Cross-sectional survey.Community based.Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point.None.Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form.Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069).Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction.

Background Individuals with headache after traumatic brain injury (TBI) receive care in a wide variety of clinical locations by physicians trained in multiple specialties. Objective To understand current practice patterns and perceptions of treatment issues among clinicians managing headache after TBI. Design National survey of current clinical practice using a 20-item questionnaire developed by the authors. Participants Survey respondents were members of the Central Nervous System Council list survey of the American Academy of Physical Medicine and Rehabilitation (N = 1782) and the American Headache Society membership (N = 1260). Methods The survey was sent electronically to potential participants and was followed by 2 biweekly reminders. The survey queried the physicians' clinical setting; their use of headache classification systems, headache diaries, checklists, and diagnostic procedures; the pharmacologic and nonpharmacologic treatments prescribed; and headache chronicity and associated symptoms and disorders among their patients with TBI. Results Completed surveys were received from 193 respondents. The use of standardized classification systems and checklists was commonly reported. Respondents used nonpharmacologic and pharmacologic treatment approaches with similar frequency and modest perceived success rates. A high frequency of headache-associated new sleep and mood disorders was reported. When response differences occurred between practice settings, they reflected a focus on headache diagnosis, classification, and pharmacologic treatment among neurology and specialty headache clinics, whereas a nonpharmacologic approach to management among TBI specialty and general rehabilitation clinicians was more commonly reported. Conclusion Management strategies for treating headache after TBI vary widely among general and specialty clinical practices. This suggests that additional research is needed that would lead to an increase in the use of established headache classification and the development of standardized management approaches so that all practitioners who care for patients after TBI can provide consistent effective care.

Amac: Bu calismanin amaclari (i), toplum icinde yasayan spinal kord yarali bireylerde uzun kemik kiriklarinin prevalansini ortaya koymak ve (ii) kirik olusumu ile fonksiyonellik ve toplumsal entegrasyon arasindaki iliskiyi tanimlamaktir. Gerec ve Yontemler: Kuzeybati Bolgesel Spinal Kord Yaralanmasi Sistemi (KBBSKYS) veri tabanindan rastgele secilen 250 hastaya calisma anketi ve onam formlari gonderildi. Hastalarin demografik parametreleri ve toplumsal entegrasyon seviyeleri KBBSKYS veri tabanindan elde edilirken, yurume indeksi skorlari ile aktivite seviyeleri gonderilen anketlerden elde edildi. Ankete cevap veren hastalar kirigi olup olmamasina gore gruplara ayrildi. Gruplar arasi farkliliklar istatistiksel olarak analiz edildi. Bulgular: Hastalardan 70 tanesi anket ve onam formlarini onaylayarak geri gonderdi. On hasta (%14) spinal kord yaralanmasi sonrasinda kirik olustugunu bildirdi. Spinal kord yaralanmasi sonrasinda gecen surenin uzun olmasi ve ileri yas, kirik olusumu ile ilintili faktorler olarak belirlendi. Sonuc: Toplum icinde yasayan spinal kord yaralanmali hastalarda kiriklar siktir ve sigara kullanimi, yas ile yaralanma sonrasi gecen surenin uzunlugu kirik olusumunu etkileyen onemli faktorlerdir. Anahtar Kelimeler: Spinal kord yaralanmasi, uzun kemik kiriklari, osteoporoz Abstract

Objective To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI). Design Longitudinal survey design with 1-year follow-up. Setting Inpatient rehabilitation and the community. Participants Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI. Interventions Not applicable. Main Outcome Measures Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥4 were classified as having pain, and participants with PHQ-9 scores ≥10 were classified as depressed. Results Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P =.003) and at year 1 (relative risk: 7.98, P Conclusions Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time.

To determine whether demographic, injury, health, and functional factors similarly have the same predictive relation with both somatic and nonsomatic symptoms of depression, as well as whether somatic and nonsomatic symptoms of depression have the same association with quality of life (QOL).Secondary analysis of cross-sectional survey data.CommunityPatients with traumatic spinal cord injury (N=4976) who completed an interview at 1 year postinjury between 2006 and 2011.Not applicable.Somatic and nonsomatic symptoms of depression from the Patient Health Questionnaire-9 and QOL measured by the Satisfaction With Life Scale.Structural equation modeling showed that the hypothesized model provided a good fit to the data, but modification of the model led to a significant improvement in model fit: Δχ(2)(1)=226.21, P.001; comparative fit index=.976; χ(2)(199)=585.39, P.001; root mean square error of approximation=.027 (90% confidence interval, .025-.030). The health-related factors including pain severity, pain interference, and health status were similarly associated with both somatic and nonsomatic symptoms of depression. QOL was negatively associated with nonsomatic symptoms of depression but was unrelated to somatic symptoms of depression.Assessment of depression after spinal cord injury should include a careful assessment of health concerns given the relation between health-related factors and both somatic and nonsomatic symptoms of depression. Treatments of depressive symptoms may be improved by targeting health concerns, such as pain, along with a specific focus on nonsomatic symptoms to improve the QOL.