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Background. In spinal cord injury, there are multiple databases containing information on functional recovery, but data cannot be pooled or compared due to differences in how function is measured. A crosswalk is needed to link or convert scores between instruments. Objectives. To create a crosswalk between the voluntary musculoskeletal movement items in the Functional Independence Measure (FIM®) and the Spinal Cord Independence Measure III (SCIM III) for spinal cord injury. Methods. Retrospective datasets with FIM® and SCIM III on the same people were used to develop (Swiss dataset, n = 662) and validate (US, n = 119, and Canadian datasets, n = 133) the crosswalks. Three different crosswalk methods (expert panel, equipercentile, and Rasch analysis) were employed. We used the correlation between observed scores on FIM® and SCIM III to crosswalked scores as the primary criterion to assess the strength of the crosswalk. Secondary criteria such as score distributions, Cohen’s effect size, point differences, and subgroup invariance were also evaluated. Results. All three methods resulted in strong correlation coefficients, exceeding the primary criterion value of r = .866 (.897–.972). Assessment of secondary criteria suggests the equipercentile and Rasch methods produced the strongest crosswalks. Conclusions. The Rasch FIM®/SCIM III crosswalk is recommended because it is based on co-calibration of linearized measures, allowing for more sophisticated parametric analyses. The crosswalk will allow comparisons of voluntary musculoskeletal functional recovery across international databases using different functional measures, as well as different systems of care and rehabilitation approaches.

This study aims to characterize the patterns of functional change experienced between 5 and 10 years after moderate-severe traumatic brain injury (TBI). The study included TBI Model Systems national database participants (N = 372) at six sites who experienced TBI, received inpatient rehabilitation, and were followed at 5 and 10 years post-TBI. Outcome measures included self- or proxy-reported Functional Independence Measure (FIM(TM)) structured interview at 5 and 10 years post-TBI and domain change indices (DCIs) at 10 years to assess subjective change over the previous 5 years. When all seven FIM and subjective DCI subscales were considered together, 69% reported improvement in at least one subscale and 41% reported decline in at least one subscale; 51% reported more domains improved than declined, and 20% reported more domains declined than improved. Age at injury, post-traumatic amnesia duration, FIM, and depression and anxiety at year 5 were associated with FIM change and DCI measures. Although most persons with moderate-severe TBI do not experience widespread change from year 5 to 10 on individual FIM subscales or perceived domain-specific subscales, the vast majority do report change in one or more domains, with more improvement than decline and more change in subjective DCI than in FIM. Clinicians and researchers should be alert to the possibility of both positive and deleterious changes many years after TBI.

Medical conditions co-occurring with traumatic brain injury (TBI) are associated with outcomes, and comorbidity indices such as Charlson and Elixhauser are used in TBI research, but they are not TBI specific. The purpose of this research was to develop an index or indices of medical conditions, identified in acute care after moderate to severe TBI, that are associated with outcomes at rehabilitation discharge. Using the TBI Model Systems National Database, the

Objective To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM. Design Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range. Setting Six TBI Model System rehabilitation hospitals. Participants Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up. Interventions Participants were administered the 49 assessment items in person or via telephone. Main Outcome Measures Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance. Results After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM. Conclusions The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

Purpose: To help enhance participation, the study aims to identify and document a comprehensive list of environmental barriers for people with SCI in the broad travel setting.Methods: Semi-structured interviews were conducted among four stakeholder groups: people with SCI (n= 39), caregivers and family members of people with SCI (n= 24), therapists who work with people with SCI (n= 9), and travel professionals specializing in accessible travel (n= 11).Results: Five major categories of travel barrier emerged from the interviews: Partial Accessibility, Systemic Ignorance, Travel Hassles, Poor Service Performance, and Lack of Support. Detailed barriers in each category are described. The analysis of multi-stakeholder perspectives indicates while respondents with SCI offered the most specific information about the barriers, family members/caregivers were most concerned about the impact of systemic ignorance on their loved ones. Therapists focused on offering their clients tools to overcome barriers, and travel agents emphasized their limitations of serving customers with disabilities.Conclusion: Results of the study should help not only health and travel professionals better assist individuals to reintegrate into society after SCI, but also travel and hospitality businesses to better meet the accessibility needs of people with SCI.Implications for rehabilitationTravel is important to full participation in society for people after SCI.The study has identified five categories of barriers to travel participation after SCI: partial accessibility, systemic ignorance, travel hassles, poor service performance and lack of support.While traveling is important for participation in society for people with SCI, rehabilitation professionals should work together with policy makers, travel and hospitality businesses and agencies to lower the found barriers.

OBJECTIVE Return to work and school following traumatic brain injury (TBI) is an outcome of central importance both to TBI survivors and to society. The current study estimates the probability of returning to productivity over 5 years following moderate to severe brain injury. DESIGN A secondary longitudinal analysis using random effects modeling, that is, individual growth curve analysis based on a sample of 2542 population-weighted individuals from a multicenter cohort study. SETTING Acute inpatient rehabilitation facilities. PARTICIPANTS Individuals 16 years and older with a primary diagnosis of TBI who were engaged in school or work at the time of injury. MAIN OUTCOME MEASURES Participation in productive activity, defined as employment or school, as reported during follow-up telephone interviews at 1, 2, and 5 years postinjury. RESULTS Baseline variables, age of injury, race, level of education and occupational category at the time of injury, disability rating at hospital discharge, substance abuse status, and rehabilitation length of stay, are significantly associated with probability of return to productivity. Individual-level productivity trajectories generally indicate that the probability of returning to productivity increases over time. CONCLUSIONS Results of this study highlight the importance of preinjury occupational status and level of education in returning to productive activity following moderate to severe TBI.

Objective To evaluate the use of Participation Assessment with Recombined Tools–Objective (PART-O) in spinal cord injury (SCI) and compare it with the Craig Handicap Assessment and Reporting Technique–Short Form (CHART-SF). Design Follow-up survey of inception cohort. Setting Community. Participants Individuals with SCI, rehabilitated at 2 large SCI Model Systems and enrolled in the SCI Model Systems National Database, who were due for routine follow-up (N=468; median age at injury, 29; median time post injury, 5 years). Interventions Not applicable. Main Outcome Measures PART-O and CHART-SF. Results Use of Rasch analysis identified an SCI-specific scoring of PART-O that demonstrated unidimensionality (first contrast eigenvalue of 1.76) with no misfitting items or disordered steps in any response categories. Person separation and reliability were 2.00 and .80, respectively. Unlike CHART-SF, PART-O had a relatively normal distribution with no floor or ceiling effects. Test-retest reliability PART-O administered 2-4 weeks apart was 0.97, with a reliable change index of 3.1 points on a 100-point scale. PART-O correlated 0.79 with the sum of 3 CHART-SF domains with similar content. The PART-O scoring was initially validated on a second data set. Conclusions PART-O can be used successfully to measure participation in a population of people with SCI. A new method of scoring PART-O in SCI provides an initially validated, univariate interval measure of participation with good psychometric properties that has advantages over the CHART-SF legacy measure of participation.

Objective To explore associations of specific physical and neuropsychiatric medical conditions to motor and cognitive functioning and life satisfaction over the first 10 years following traumatic brain injury (TBI). Setting Telephone follow-up through 6 TBI Model System centers. Participants In total, 404 individuals or proxies with TBI enrolled in the TBI Model System longitudinal study participating in 10-year follow-up. Design Individual growth curve analysis. Main measures FIM Motor and Cognitive subscales, Satisfaction With Life Scales, and Medical and Mental Health Comorbidities Interview. Results Hypertension, diabetes, cancers, rheumatoid arthritis, and anxiety negatively affected the trajectory of motor functioning over time. Diabetes, cancers, chronic bronchitis, anxiety, and depression negatively impacted cognitive functioning. Numerous neuropsychiatric conditions (sleep disorder, alcoholism, drug addiction, anxiety, panic attacks, posttraumatic stress disorder, depression, and bipolar disorder), as well as hypertension, liver disease, and cancers, diminished life satisfaction. Other medical conditions had a negative effect on functioning and satisfaction at specific follow-up periods. Conclusion Natural recovery after TBI may include delayed onset of functional decline or early recovery, followed by progressive deterioration, and is negatively affected by medical comorbidities. Results contribute to the growing evidence that TBI is most appropriately treated as a chronic medical condition complicated by a variety of comorbid conditions.

PURPOSE/OBJECTIVE The objective of the study was to evaluate the extent to which 1- and 2-year outcomes after traumatic brain injury (TBI) are predicted by resilience. Research Method/Design: This was an observational, longitudinal study of persons (n = 158) with moderate or severe TBI who completed both 1- and 2-year outcome assessments. Outcomes included anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), life satisfaction (Satisfaction with Life Scale), substance misuse, and return-to-work measures. The Connor-Davidson Resilience Scale was used to assess resilience at 3 or 6 months after injury. RESULTS Greater resilience predicted less anxiety, depression, and substance use and better satisfaction with life and return to work at 1 year after injury for both adjusted and unadjusted models. Standardized regression coefficients were all greater than 0.38 for continuous outcomes, whereas odds ratios were 1.34 and 0.81 for the return to work and substance misuse outcomes, respectively (p < .05). Similar but weaker trends were found at 2 years after injury, with statistical significance no longer met for all outcomes. CONCLUSIONS/IMPLICATIONS Resilience was shown to have predictive ability for outcomes at 1 and 2 years after TBI. Resilience appears to be a salient and important variable for long-term outcomes in person with TBI after adjusting for injury and demographic characteristics. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation. Design Retrospective cohort. Setting Six TBI Model Systems (TBIMS) centers. Participants In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior. Interventions Not applicable. Main outcome measure Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity. Results At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders. Conclusions People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

OBJECTIVE: To examine associations of patient characteristics and treatment quantity delivered during inpatient spinal cord injury (SCI) rehabilitation with outcomes at 5 years post-injury and compare them to the associations found at 1 year post-injury. DESIGN: Observational study using Practice-Based Evidence research methodology in which clinicians documented treatment details. Regression modeling was used to predict outcomes. SETTING: Five inpatient SCI rehabilitation centers in the US. PARTICIPANTS: Participants were 792 SCIRehab participants who were >12 years of age, gave informed consent, and completed both a 1-year and 5-year post-injury interview. OUTCOME MEASURES: Outcome data were derived from Spinal Cord Injury Model Systems (SCIMS) follow-up interviews at 5 years post-injury and, similar to the 1-year SCIMS outcomes, included measures of physical independence, societal participation, life satisfaction, and depressive symptoms, as well as place of residence, school/work attendance, rehospitalization, and presence of pressure ulcers. RESULTS: Consistent with 1-year findings, patient characteristics continue to be strong predictors of outcomes 5-years post-injury, although several variables add to the prediction of some of the outcomes. More time in physical therapy and therapeutic recreation were positive predictors of 1-year outcomes, which held less true at 5 years. Greater time spent with psychology and social work/case management predicted greater depressive symptomatology 5-years post-injury. Greater clinician experience was a predictor at both 1- and 5 -years, although the related positive outcomes varied across years. CONCLUSION: Various outcomes 5-years post-injury were primarily explained by pre-and post-injury characteristics, with little additional variance offered by the quantity of treatment received during inpatient rehabilitation.

While a substantial literature has examined the effects of individual and family-level factors on outcomes following traumatic brain injury (TBI), minimal attention has been directed to the potential influence of the larger environmental context on outcomes. The purpose of the current study was to investigate the effects of state-level resources and supports as an environmental factor influencing long-term outcomes from TBI using data from the TBI Model Systems. We examined the effects of U.S. state supports that specifically target people with TBI (federal funding for state brain injury programs, per capita revenue generated by brain injury trust funds, and expenditures for brain injury specific Medicaid waivers) and one measure of the relative quality of a state's Long-Term Services and Supports (LTSS) for all people with disabilities. The primary hypothesis was that community participation, global functioning, and life satisfaction will be higher on average among people with TBI living in states with more brain injury specific programs and resources and better LTSS. The results of multilevel and fixed-effects modeling indicated that state supports have a small but significant impact on participation and life satisfaction. The most consistent finding indicated that states with better LTSS had higher levels of community participation and life satisfaction on average for people with TBI over and above individual-level differences and fluctuations in these outcomes over time. There was some indication that more brain injury specific supports also result in better participation in the community. These findings deserve replication and extension to include other environmental factors, particularly community level characteristics, that might affect outcomes from TBI.

This was a secondary analysis on an observational cohort study. To determine if serum albumin significantly associates with long-term neurological outcome (i.e., 1-year post-injury) in a contemporary cohort of individuals with spinal cord injury. Six rehabilitation centers across the United States. A secondary analysis of neurological outcomes and serum albumin concentrations was performed on data from the Spinal Cord Injury Rehabilitation study. Data was accessed from the Archive of Data on Disability to Enable Policy and research (ADDEP). The primary analysis applied unbiased recursive partitioning to examine the relationship between serum albumin, injury severity, and long-term outcomes. The analysis is accessible via https://rpubs.com/AnhKhoaVo/586028 . Serum albumin concentration was significantly associated with lower extremity motor scores (LEMS) and American Spinal Injury Association Impairment Scale (AIS) grade at admission to rehabilitation. Serum albumin concentrations alone were also significantly associated with change of LEMS and marked recovery (improvement of at least 2 AIS grades and/or recovery to walking) at 1-year post injury. However, after adjusting for admission to rehabilitation LEMS and AIS grade, serum albumin was not significant. The current study partially confirms our previous observations that serum albumin concentrations are associated with neurological outcome after spinal cord injury. As a crude prognostic biomarker, serum albumin concentration could be useful in cases where injury severity cannot be accurately assessed.

Objective To examine the association between social Internet use and real-world societal participation in survivors of moderate-severe traumatic brain injury. Design Prospective cross-sectional observational study. Setting Ten Traumatic Brain Injury Model Systems Centers. Participants A total of 331 participants in the Traumatic Brain Injury Model Systems, interviewed at any follow-up year between April 2014 and March 2015. Main measures Survey on Internet use, including social media and other online socialization; Participation Assessment with Recombined Tools-Objective with separate analyses of Productivity, Social Relations, Out and About subscales; covariates included demographics, injury variables, and functional and emotional status at follow-up. Results Participants were classified as social Internet users (N = 232) or nonusers (N = 99). Users had significantly higher Participation Assessment with Recombined Tools-Objective Social Relations scores than nonusers. A similar finding pertained to Out and About scores, with the between-group difference significantly greater for those with greater depressive symptoms severity. Users and nonusers did not differ significantly on Productivity subscale. Conclusions The positive association between social Internet use and real-world social participation suggests that people with traumatic brain injury do not use social media as an alternative to real-world socialization. Rather, it is likely that similar barriers and facilitators affect both online and real-world social participation following traumatic brain injury. Emotional function should be considered as a moderating factor in further studies.

Objective To determine whether rehospitalization during the first 2 years after moderate to severe traumatic brain injury (TBI) is associated with poor participation at 5 years post-TBI, after controlling for demographic and severity factors. Setting TBI Model Systems Program. Participants Community-dwelling individuals with TBI, 16 years or older (n = 1940). Design Retrospective data analysis of a multicenter prospective study. Main measures Participation Assessment with Recombined Tools-Objective (PART-O). Results After controlling for demographic and severity factors, a general linear model indicated that rehospitalization status (ie, never rehospitalized during years 1 and 2, rehospitalized either during year 1 or 2, or rehospitalized during both years 1 and 2) predicted less participation at 5 years post-TBI (P = .0353). The PART-O scores were in the hypothesized direction, with the lowest covariate-adjusted mean participation score found for the group with rehospitalizations during both years and the highest covariate-adjusted mean participation score found in the group with no rehospitalizations. Examining total number of rehospitalizations during years 1 and 2, rather than rehospitalization status, yielded analogous results (P = .0148). Conclusions This study suggests that rehospitalization in the first 2 years after TBI is negatively associated with participation at 5 years after injury. Since participation is considered a key indicator of successful TBI rehabilitation, minimizing the need for rehospitalizations and promoting health in the community setting should be a priority of postacute care for individuals with TBI.

Participation is often considered a primary goal of traumatic brain injury (TBI) rehabilitation, but little is known about the influence of driving on participation after TBI. The objective of this study was to examine the independent contribution of driving status to participation at 5 years post TBI, after controlling for demographic, psychosocial, and functional factors. Participants ( N = 2,456) were community-dwelling individuals with moderate to severe TBI, age 18 to 65 at time of injury, and enrolled in the TBI Model Systems (TBIMS) National Database (NDB). Hierarchical linear regressions for the dependent variable of participation at 5 years post TBI were performed. Findings showed that driving was a highly significant independent predictor of participation and was a stronger relative predictor of participation than FIM® Cognitive, FIM® Motor, and depression. The independent contribution of driving to participation suggests the need to develop evidenced-based occupational therapy assessments and interventions that facilitate safe engagement in the occupation of driving to address the long-term goal of improved participation.

Objective To examine the construct validity of the Participation Measure–3 Domains, 4 Dimensions (PM-3D4D), a multidimensional participation measure developed for use in rehabilitation practice. Design Cross-sectional study. Setting Outpatient rehabilitation programs. Participants Rehabilitation patients (N=556; mean age, 61.4±23.6y; 47.1% women). Interventions Not applicable. Main Outcome Measures The PM-3D4D is a 19-item measure designed to evaluate participation in 3 domains—Productivity, Social, and Community—across 4 dimensions—Diversity, Frequency, Desire for change, and Difficulty. Intercorrelations among the 4 dimensions of the PM-3D4D and correlations between the PM-3D4D and 3 legacy instruments—Participation Assessment with Recombined Tools-Objective, Participation Measure for Post-Acute Care, and Satisfaction With Life Scale—were examined to establish the convergent and divergent validity of the PM-3D4D. Known-group validity was evaluated by comparing PM-3D4D scores across age groups and groups of people classified by functional level. Results The Diversity scale of the PM-3D4D was strongly correlated with the Frequency scale (Spearman correlation coefficient, r s =.83–.96 across the 3 domains), and these 2 scales showed moderate to strong correlations with the Difficulty scale ( r s =.42–.70) but weak ( r s =−.4 to 0) and insignificant correlations with the Desire for change scale. The Frequency and Difficulty scales of the PM-3D4D showed moderate to strong correlations with the Participation Assessment with Recombined Tools-Objective and Participation Measure for Post-Acute Care ( r s =.41–.82), respectively, and the Desire for change scale had weak correlations with the Satisfaction With Life Scale ( r s =−.32 to −.18). Significant differences in PM-3D4D scores were found by age and functional level. Conclusions Findings of this study support the construct validity of the PM-3D4D, providing evidence for using the PM-3D4D to assess rehabilitation patients' participation performance and helping practitioners identify intervention priorities to improve patients' participation outcomes.

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

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

Purpose/objective The purpose of this study was to evaluate the psychometric properties of 2 novel measures assessing personal advocacy, self-efficacy and personal advocacy activities in individuals with acquired brain injury (ABI). Design This was an instrument development study using (a) expert panel review with a content validity index, (b) consumer survey, and (c) Rasch analysis. Participants were adults (N = 162) with ABI recruited through a community survey. Main outcome measure Participants completed the Self-Advocacy Scale (SAS) and the Personal Advocacy Activity Scale (PAAS). Results Using Rasch analysis to inform instrument development, after modification on the basis of item response theory analysis, the SAS, a measure of advocacy self-efficacy, was found to be unidimensional with an eigenvalue of 1.6, exhibited monotonicity, and had an item reliability of 0.97. Similarly, the PAAS, a measure of advocacy activity, was found to exhibit monotonicity, is unidimensional (eigenvalue of 1.7) and had an item reliability of 0.97. Both measures demonstrated concurrent validity, because they were significantly correlated with other established measures of related constructs and with each other. A separation reliability of 0.97 (real not model) for both the SAS and PAAS suggests that items will likely hold their relative positions in a similar sample. Conclusions This study supported the PAAS and the SAS as reliable and valid measures of personal advocacy activity and associated self-efficacy in individuals post-ABI. (PsycINFO Database Record

Objective To examine resilience at 3 months after traumatic brain injury (TBI). Design Cross-sectional analysis of an ongoing observational cohort. Setting Five inpatient rehabilitation centers, with 3-month follow-up conducted primarily by telephone. Participants Persons with TBI (N=160) enrolled in the resilience module of the TBI Model System study with 3-month follow-up completed. Interventions Not applicable. Main Outcome Measure Connor-Davidson Resilience Scale. Results Resilience scores were lower than those of the general population. A multivariable regression model, adjusting for other predictors, showed that higher education, absence of preinjury substance abuse, and less anxiety at follow-up were significantly related to greater resilience. Conclusions Analysis suggests that lack of resilience may be an issue for some individuals after moderate to severe TBI. Identifying persons most likely at risk for low resilience may be useful in planning clinical interventions.

Neuroprotective treatments that have shown promise in reducing secondary injury and improving recovery in animal models of traumatic brain injury (TBI) have not been found effective to date in humans. One reason may be the delay after injury in initiating treatment. Statin medications are among the promising neuroprotective agents in animal models, and their presence in the bloodstream of many individuals at the time of injury might optimize their clinical impact. This observational study conducted by a subset of centers participating in the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR)-funded TBI Model System program sought to examine the effects of taking statin medication at the time injury on functional outcomes. Participants >50 years of age were prospectively enrolled during patient rehabilitation. Demographic data, cardiovascular history, and brain injury history were obtained through chart abstraction and interview. Prescription medication use in the year prior to enrollment was determined from a national pharmacy search service. Propensity scoring was used to create 49 pairs of participants who were well matched on demographic and clinical attributes but discordant for statin use. The treated and untreated participants did not differ on initial Glasgow Coma Score, time until commands were followed, duration of post-traumatic amnesia, or Functional Independence Measure (FIM) scores at rehabilitation admission, discharge, or 1 year post-injury, or on acute or rehabilitation hospital lengths of stay. Evidence of greater and lesser statin compliance was not associated with outcome. This study did not provide support for a clinically important benefit of statin use at the time of moderate to severe TBI.

Traumatic brain injury (TBI) often results in cognitive impairment, and trajectories of cognitive functioning can vary tremendously over time across survivors. Traditional approaches to measuring cognitive performance require face-to-face administration of a battery of objective neuropsychological tests, which can be time- and labor-intensive. There are numerous clinical and research contexts in which in-person testing is undesirable or unfeasible, including clinical monitoring of older adults or individuals with disability for whom travel is challenging, and epidemiological studies of geographically dispersed participants. A telephone-based method for measuring cognition could conserve resources and improve efficiency. The objective of this study is to examine the feasibility and usefulness of the Brief Test of Adult Cognition by Telephone (BTACT) among individuals who are 1 and 2 years post–moderate-to-severe TBI. A total of 463 individuals participated in the study at Year 1 post-injury, and 386 participated at Year 2. The sample was mostly male (73%) and white (59%), with an average age of (mean ± standard deviation) 47.9 ± 20.9 years, and 73% experienced a duration of post-traumatic amnesia (PTA) greater than 7 days. A majority of participants were able to complete the BTACT subtests (61–69% and 56–64% for Years 1 and 2 respectively); score imputation for those unable to complete a test due to severity of cognitive impairment yields complete data for 74–79% of the sample. BTACT subtests showed expected changes between Years 1–2, and summary scores demonstrated expected associations with injury severity, employment status, and cognitive status as measured by the Functional Independence Measure. Results indicate it is feasible, efficient, and useful to measure cognition over the telephone among individuals with moderate-severe TBI.

Objective To develop an environmental-barriers scale, Travel Restrictions Influencing Participation (TRIP), in the context of travel for people living with spinal cord injury (SCI). Design A mixed-method approach where, in the qualitative phase, items were developed and written based on results of interviewers with different stakeholder groups and, in the quantitative phase, survey data were collected to examine the psychometric properties of the scale. Setting Home, work, and community settings. Participants People living with SCI, caregivers/family members, therapists, and travel professionals (N=333). Interventions None. Main Outcome Measures A 19-item TRIP scale that measures the travel barriers encountered by people with SCI. Results Results from 83 semi-structured in-depth interviews with 4 stakeholder groups guided the writing of items in the TRIP scale. Seven cognitive interviews and an expert panel conducted reviews for content validity of the scale, and 19 items were included in the quantitative assessment of the scale. A total of 250 patients enrolled in the Rocky Mountain Regional Spinal Injury System was systematically selected to report their experience with each travel barrier. Item-response theory–based Rasch analysis revealed that TRIP has acceptable psychometric properties. Conclusions The 19-item TRIP scale demonstrates promising psychometric properties for the scale to be used in clinical settings to quickly identify environmental barriers individuals with SCI encounter when traveling. It has the potential to assist with developing interventions that will improve the travel experience of individuals with SCI or to assist with strategies to overcome travel barriers.

Objective To identify factors that predict trajectories of participation over the first 5 years after moderate to severe traumatic brain injury (TBI). Setting TBI Model System Programs. Participants Community-dwelling individuals with TBI, 16 years of age or older (n = 1947). Design Secondary analysis of a prospective, nonrandomly sampled, longitudinal data registry. Main measures Participation Assessment with Recombined Tools-Objective (PART-O). Results Age at injury and FIM Motor score predicted trajectory of participation over the first 5 years after moderate to severe TBI. Older age predicted generally worse participation overall as well as progressively worsening participation over time. Higher FIM Motor raised the predicted participation values, although it reduced the rate of improvement in participation scores over time. FIM Cognitive scores, race, depression, years of education, and living setting did not predict trajectory but did significantly influence participation consistently at all time points. Conclusion The trajectories of participation over the first 5 years after TBI can be predicted by age at injury and FIM Motor scores. These findings may enhance the ability of rehabilitation professionals to identify individuals at risk for poor participation after TBI and develop targeted interventions for optimizing involvement in life activities.

OBJECTIVE:: To estimate the overall and by age-group characteristics at admission and discharge from rehabilitation between 2001 and 2010 of all late-teens and adults undergoing inpatient rehabilitation for a primary diagnosis of traumatic brain injury (TBI) in the United States. DESIGN:: Secondary data analysis. SETTING:: Acute inpatient rehabilitation facilities. PARTICIPANTS:: Patients aged 16 years and older receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001 and 2010. MAIN OUTCOME MEASURES:: Functional independence, level of disability, and living situation. RESULTS:: The incidence of TBI by age group found the largest proportion of cases to be aged 80 years and older, with a gradual decline in incidence in the age group of 30 years, at which point there was a slight increase. Injuries resulted predominantly from falls (49.8%) and motor vehicle crashes (40.8%); however, injuries to the youngest individuals were largely from motor vehicle crashes with decreasing rates as age increased, while injuries due to falls rose as age increased, with the oldest age groups most likely to incur a TBI. Preinjury alcohol misuse and substance use were found to occur in 22.9% and 12.2% of the total population, respectively; however, age distributions demonstrated high preinjury use among individuals younger than 50 years (eg, 46.4% and 30.6% for those aged 20 and 29 years, respectively) with decreasing misuse as age increased. Of the total population, 49.2% were retired, 31.1% employed, 14.1% not working, and 5.6% students. Trends by age showed that younger individuals were more likely to be students or employed (eg, 14.5% and 62.0% for those aged 20 and 29 years, respectively), with employment status peaking for those aged 30 to 39 years, and declining to 3.2% for the oldest age group (80 years and older). The trend of person(s) living alone between pre- and postrehabilitation showed the least amount of change for those aged 16 to 19 years with steadily increasing changes as age increased. Similar trends were seen for residence changes pre- and postrehabilitation, with the youngest most likely to return to living at a private residence, and a gradual decrease in return to living at a private residence as age increased. FIM instrument ("FIM") Motor and Cognitive subscale scores demonstrated that younger individuals had lower scores at admission to rehabilitation and higher scores at rehabilitation discharge. CONCLUSION:: This study provides population estimates for all patients 16 years of age and older receiving inpatient rehabilitation for a primary diagnosis of TBI in the United States between 2001 and 2010. A recent trend shows the aging of the inpatient TBI rehabilitation population. Many characteristics important to rehabilitation outcomes are influenced by age, with older individuals trending toward being female, having less severe TBIs, incurring TBIs as a result of falls, but showing less improvement during rehabilitation, greater resulting disability, and more changes in their living situation postrehabilitation. These findings are of particular interest, as the oldest age groups considered in these analyses did not include the baby boom population. Language: en

Background and Purpose— Traumatic brain injury (TBI) leads to nearly 300 000 annual US hospitalizations and increased lifetime risk of acute ischemic stroke (AIS). Occurrence of AIS immediately after TBI has not been well characterized. We evaluated AIS acutely after TBI and its impact on outcome. Methods— A prospective database of moderate to severe TBI survivors, admitted to inpatient rehabilitation at 22 Traumatic Brain Injury Model Systems centers and their referring acute-care hospitals, was analyzed. Outcome measures were AIS incidence, duration of posttraumatic amnesia, Functional Independence Measure, and Disability Rating Scale, at rehabilitation discharge. Results— Between October 1, 2007, and March 31, 2015, 6488 patients with TBI were enrolled in the Traumatic Brain Injury Model Systems National Database. One hundred and fifty-nine (2.5%) patients had a concurrent AIS, and among these, median age was 40 years. AIS was associated with intracranial mass effect and carotid or vertebral artery dissection. High-velocity events more commonly caused TBI with dissection. AIS predicted poorer outcome by all measures, accounting for a 13.3-point reduction in Functional Independence Measure total score (95% confidence interval, −16.8 to −9.7; P P P Conclusions— Ischemic stroke is observed acutely in 2.5% of moderate to severe TBI survivors and predicts worse functional and cognitive outcome. Half of TBI patients with AIS were aged ≤40 years, and AIS patients more often had cervical dissection. Vigilance for AIS is warranted acutely after TBI, particularly after high-velocity events.

Objectives To characterize Internet and social media use among adults with moderate to severe traumatic brain injury (TBI) and to compare demographic and socioeconomic factors associated with Internet use between those with and without TBI. Setting Ten Traumatic Brain Injury Model Systems centers. Participants Persons with moderate to severe TBI (N = 337) enrolled in the TBI Model Systems National Database and eligible for follow-up from April 1, 2014, to March 31, 2015. Design Prospective cross-sectional observational cohort study. Main measures Internet usage survey. Results The proportion of Internet users with TBI was high (74%) but significantly lower than those in the general population (84%). Smartphones were the most prevalent means of Internet access for persons with TBI. The majority of Internet users with TBI had a profile account on a social networking site (79%), with more than half of the sample reporting multiplatform use of 2 or more social networking sites. Conclusion Despite the prevalence of Internet use among persons with TBI, technological disparities remain in comparison with the general population. The extent of social media use among persons with TBI demonstrates the potential of these platforms for social engagement and other purposes. However, further research examining the quality of online activities and identifying potential risk factors of problematic use is recommended.

Objective Evaluate the test-retest reliability of measures that comprise the Traumatic Brain Injury Model Systems follow-up data set. Participants A total of 224 persons with a moderate-severe traumatic brain injury (TBI) enrolled in the Traumatic Brain Injury Model Systems National Database. Design Following standard administration of the follow-up interview, a second interview was administered 14 to 28 days later using the same interviewer and the same mode of administration. Main measures Traumatic Brain Injury Model Systems follow-up interview that includes 66 variables comprised (a) single item measures of demographics; employment; general health as well as specific health conditions; rehospitalization; tobacco, alcohol, and other drug use; transportation; and mental health and (b) multi-item instruments: FIM; Participation Assessment With Recombined Tools-Objective; Disability Rating Scale; Glasgow Outcome Scale-Extended; Supervision Rating Scale; Satisfaction With Life Scale; TBI Quality of Life Anxiety and Depression items; and The Ohio State University TBI Identification Method. Results Intraclass correlation coefficient values ranged from 0.65 to 0.99, weighted kappa values ranged from 0.54 to 0.99, and kappa values ranged from 0.43 to 1.00. Four kappa/weighted kappa estimates fell below 0.60: arrested, psychiatric hospitalization, number of days not in good physical health, and rating of general emotional health. Conclusions With few exceptions, good to excellent test-retest reliability estimates were obtained. The findings support the use of these measures in prior and future studies and indicate that persons with moderate-severe TBI can provide reliable self-report.

Objective The purpose of this paper was to report on the first step in the development of a new instrument to measure participation including the full range of its characteristics. Methods The 30-item participation behavior questionnaire (PBQ) was developed from four main sources (a literature review of the theatrical basis of participation, available participation measures, and interviews with patients and experts about participation). Item selection and the reliability and validity of the measure were explored using Rasch measurement modeling for analysis. Participants A total of 404 individuals referred to rehabilitation after hand, wrist, or upper extremity surgery to reduce impairment from trauma, at least 2 months post-injury. Results An initial pool of 100 items; reflecting 14 characteristics of participation was initially reduced to 91 items after review by 15 participation experts and then further reduced to 30 items by three rounds of Rasch analysis removing misfitting items. The final PBQ has a person reliability of 0.91 with separation of 3.22, indicating it can reliably differentiate four levels of participation. There are no misfitting items and the instrument is unidimensional. All 14 characteristics of participation were retained in the PBQ, and none of the 30 items refer specifically to upper extremity issues. Conclusion The 30 participation behavior items of the PBQ show promise of being a psychometrically sound measure of participation. Further research is needed to validate the PBQ in samples of people with a range of other disabilities.

Objective To evaluate the psychometric properties and validity of an expanded set of community enfranchisement items that are suitable for computer adaptive testing. Design Survey. Setting Community setting. Participants Individuals with disabilities (N=1163) were recruited from an online panel generation company (51%), former rehabilitation inpatients (18%), disability community organizations (13%), a registry of rehabilitation patients (10%), and Traumatic Brain Injury and Spinal Cord Injury Model System facilities (8%). Inclusion criteria were a self-identified disability, aged ≥18 years, and the ability to read and speak English. Interventions None. Main Outcome Measure Community enfranchisement. Results Exploratory and confirmatory factor analyses of the 48 enfranchisement items suggested 2 distinct subsets of items: (1) importance of participation and (2) control over participation. Principal components analysis of the residuals suggested that the 2 item sets are unidimensional. Rating scale analysis provided evidence that the 2 item sets fit the Rasch model. Importance and control were moderately correlated with each other and with disability severity. Conclusions Importance of participation and control over participation define 2 distinct sets of participation enfranchisement. Preliminary evidence supports their validity.

Objectives To describe the application of practice-based evidence (PBE) methodology to spinal cord injury (SCI) rehabilitation in the SCIRehab study, and to summarize associations of patient characteristics and treatment interventions to outcomes. Design Prospective observational study. Setting Six SCI rehabilitation centers. Participants Patients with traumatic SCI (N=1376) admitted for first rehabilitation. Interventions Not applicable. Main Outcome Measures FIM and residence at discharge, and FIM, residence, Craig Handicap Assessment and Reporting Technique, work/school status, Patient Health Questionnaire-9, Diener Satisfaction with Life Scale, rehospitalization, and presence of pressure ulcers at 1 year postinjury. Results Patient demographic and injury characteristics explained significant variation in rehabilitation outcomes, particularly functional outcomes. Regression modeling also identified a large number of significant associations with outcomes when total time in each discipline was modeled and when models were developed for each discipline, examining time spent in the many specific interventions provided by each discipline. Conclusions The application of PBE methodology in the SCIRehab study provided extensive information about the process of inpatient SCI rehabilitation. While patient demographic and injury characteristics explain substantial variation in rehabilitation outcomes, particularly functional outcomes, significant relations also were found between the type and quantity of treatment interventions delivered by each rehabilitation discipline and a broad range of outcomes.

To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4-24.2). Total motor score averaged 39.2 (95% CI 37.8-40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P = 0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.

To evaluate the effects of psychological interventions on rehabilitation outcomes, including residence and functional status at discharge, and residence, school attendance, or employment, and physical, social, occupational, and mobility aspects of participation 1 year after spinal cord injury (SCI).Prospective observational cohort study.Six inpatient rehabilitation facilities in the United States.Inpatients with SCI 12 years of age and older.Usual rehabilitation care.Functional Independence Measure at rehabilitation discharge and 1-year injury anniversary; discharge destination and residence at 1-year anniversary; Craig Handicap Assessment and Reporting Technique, Diener Satisfaction with Life Scale, Patient Health Questionnaire, employment or school attendance, rehospitalization, and occurrence of a pressure ulcer at 1-year anniversary.More time in psycho-educational interventions was associated with better function, discharge to home, home residence at 1 year, and the absence of pressure ulcers at 1 year. More psychotherapeutic sessions focusing on processing emotions and/or locus of control were associated with poorer function at discharge and 1 year, less physical independence and community mobility, lower satisfaction with life, and the presence of pressure sores at 1 year.Psychological services are an important component of comprehensive medical rehabilitation and tailored to patient needs and readiness to benefit from rehabilitation. Services focused on remediating deficits tend to be associated with negative outcomes, while services intended to foster adjustment and growth tend to be associated with favorable outcomes. Further research is needed to determine the optimal type and timing of psychological services during inpatient rehabilitation based on individuals' strengths and vulnerabilities. Note: This is the sixth in this third series of SCIRehab articles.

Describe associations of patient characteristics and speech-language pathology (SLP) interventions provided during impatient rehabilitation for spinal cord injury (SCI) to outcomes at discharge and 1-year post-injury.Speech-language pathologists at six inpatient rehabilitation centers documented details of treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary. Cognitive, participation, and mood outcomes for a subsample of patients with traumatic brain injury (TBI) and cognitive-communication limitations (CCLs) were examined.SLP treatment factors explain a small amount of variation in cognitive Functional Independence Measure (FIM), participation, and mood. Variation explained by treatment factors for cognitive outcomes at the time of discharge increased when the patient group was more homogeneous (patients with TBI and CCLs). More time in SLP cognitive-communication interventions had a negative relationship, while longer length of stay was positive. The added explanatory power was not seen for similar outcomes at 1-year post-injury.Patients with SCI who have the greatest need for interventions to address cognitive limitations due to TBI receive the most SLP cognitive-communication treatment and show the greatest amount of improvement during rehabilitation. Their cognitive functioning remained impaired at discharge; this likely accounts for the consistent finding that more hours of SLP cognitive-communication treatment is associated with lower cognitive FIM scores at discharge. Future research on individuals with dual SCI and TBI should include more comprehensive assessment of individual differences in cognitive performance in order to better examine the complex relationships between SLP treatments and outcomes. Note: This is the fifth of nine articles in this SCIRehab series.

To investigate associations of social work/case management (SW/CM) services during inpatient rehabilitation following spinal cord injury (SCI) and patient characteristics with outcomes.Prospective observational cohort of individuals with SCI receiving inpatient rehabilitation.Six inpatient rehabilitation centers.1032 individuals with traumatic SCI.Not applicable.Type of residence at the time of rehabilitation discharge. Employment/school status, presence of a pressure ulcer, Patient History Questionnaire, Satisfaction with Life Scale, Craig Handicap Assessment and Reporting Technique (CHART) subscales, and rehospitalization at 1-year post-injury.The intensity of specific SW/CM services is associated with multiple outcomes examined. More sessions dedicated to discharge planning for a home discharge and financial planning were associated positively with more discharge to home, while more sessions focused on planning for discharge to a location other than home, e.g. nursing home or long-term acute care facilities, have negative associations with societal participation outcomes (CHART Social Integration, Occupation, and Mobility scores) as well as with residing at home at the time of the 1-year injury anniversary.The intensity and type of SW/CM services are associated with outcomes at rehabilitation discharge and at 1-year post-injury. Discharge to home may require assistance from SW/CM in the area of discharge planning and financial planning, while discharge to non-home residence demands directed SW/CM services for such placement. Note: This is the eighth of nine articles of this SCIRehab series.

Jette AM, Tulsky DS, Ni P, Kisala PA, Slavin MD, Dijkers MP, Heinemann AW, Tate DG, Whiteneck G, Charlifue S, Houlihan B, Williams S, Kirshblum S, Dyson-Hudson T, Zanca J, Fyffe D. Development and initial evaluation of the Spinal Cord Injury-Functional Index. Objectives To describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain. Design Cross-sectional survey followed by calibration data simulations. Setting Inpatient and community settings. Participants A sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury. Interventions None. Main Outcome Measure SCI-FI instrument. Results Item response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks. Conclusions Initial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI.

Bogner JA, Whiteneck GG, Corrigan JD, Lai J-S, Dijkers MP, Heinemann AW. Comparison of scoring methods for the Participation Assessment with Recombined Tools–Objective. 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.

Heinemann AW, Lai J-S, Magasi S, Hammel J, Corrigan JD, Bogner JA, Whiteneck GG. Measuring participation enfranchisement. Objective To reflect the perspectives of rehabilitation stakeholders in a measure of participation enfranchisement that can be used by people with and without disabilities. Design Survey. Setting Community settings. Participants We pilot-tested a draft instrument with 326 adults who had sustained stroke, spinal cord injury, traumatic brain injury, or other disabling condition, as well as a general population sample. We administered a revised version of the instrument to a statewide sample drawn from the 2006 Colorado Behavioral Risk Factors Surveillance System that included persons with (N=461) and without (N=451) self-identified activity limitations. Interventions None. Main Outcome Measure Participation enfranchisement. Results We used multidimensional scaling, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), followed by rating scale analysis to evaluate the psychometric properties of the instrument. EFA identified 3 participation enfranchisement factors that describe perceived choice and control, contributing to one's community, and feeling valued; the factors were supported marginally by CFA. Rating scale analysis revealed marginal person separation and no misfitting items. Conclusions Participation enfranchisement constitutes a new, previously unmeasured aspect of participation—one that addresses subjective perceptions rather than objective performance—with items that are clearly distinct from more generalized satisfaction with participation. The 19 enfranchisement items describe aspects of participation that may prove useful in characterizing longer-term rehabilitation outcomes.

Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, Backus D, Charlifue S, Ballard PH, Zanca JM. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab study. Objective To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI). Design Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview. Setting Inpatient and postdischarge rehabilitation programs. Participants Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study. Interventions Not applicable. Main Outcome Measures Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews. Results Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services. Conclusions SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes.

Background/objectiveLength of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs.MethodsSix hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and with...

Introduction/Background Participation is a key concept in the International Classification of Functioning, Disability, and Health and a central rehabilitation outcome, but agreement on measuring participation is lacking. Participation Assessed with Recombined Tools–Objective (PART-O) was developed for traumatic brain injury (TBI), used in the TBI Model Systems, and endorsed as a common data element. However, the content of PART-O is not unique to TBI and the instrument may be applicable to other populations. The aim of this research is to determine the psychometric properties of PART-O in people with spinal cord injury (SCI). Material and method The PART-O items were administered to 468 people with SCI from 4 months to 40 years post injury along with the most frequently used measure of participation in SCI: the Craig Handicap Assessment and Reporting Technique (CHART). The PART-O was administered a second time, 2–4 weeks later to assess test-retest reliability. Rasch analysis was used to ensure a unidimensional linear measure and evaluate the psychometric properties of PART-O in SCI. Results To achieve unidimensionality and maintain ordered steps within item categories, 3 competing items (hours per week spent working, in school, and homemaking) were summed into a testlet, and infrequently endorsed categories were combined. The resulting measure was unidimensional (first contrast less than 2.00) with all items fitting well (no infit or outfit above 1.40 and no disordered categories in any item), and acceptable person separation (2.00) and reliability (0.80). PART-O had a normal distribution with no ceiling or floor effects. The test-retest reliability was 0.97 and the correlation between PART-O and CHART was 0.79. Conclusion The PART-O shows promise for expanding its use into SCI. It is highly correlated with the legacy CHART instrument, and it has advantages over CHART, of being a normally distributed linear measure without ceiling effects.