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To identify factors associated with health-care utilization during the first year after inpatient rehabilitation (IR) in individuals with traumatic spinal cord injury (SCI).Prospective cohort.One hundred and sixty-eight patients were prospectively enrolled and followed over 1 year after discharge from an SCI Model System IR program. Telephone follow-up occurred at 3, 6, 9, and 12 months. Participants were grouped into four impairment levels (C1-4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-C, C5-C8 AIS A-C, paraplegia AIS A-C, and all AIS D). Three domains of health-care utilization were examined: hospital care, outpatient provider visits, and home services.Health-care utilization in the first year following IR was high with 45% of subjects reporting re-hospitalization. Twenty percent of patients were initially discharged to a skilled nursing facility (SNF), and an additional 10% required SNF care during this first year. Overall, those with C1-4 AIS A-C used the most services. Participants discharged home used less health care compared to those discharged elsewhere. SCI due to falls (vs. vehicular crashes) was associated with fewer in-home service visits. Age, sex, race, and education were unrelated to higher use.Those with greater neurological impairment or not discharged home after IR had higher health-care utilization, while age was not associated with utilization. Targeted efforts to reduce genitourinary and respiratory complications may reduce the need for hospital care in the first year after IR.

Symptoms of concussion are divided into three major domains: physical, cognitive, and emotional. These symptoms including headache, neck pain, vision changes, cognitive deficits, and emotional changes can be seen immediately after the injury and usually resolve within the first 3 months. However, some of these symptoms may persist for several months afterward. Risk factors have been identified for prolonged symptoms. Certain early interventions may decrease persistent symptoms. In this chapter, we discuss common acute and persistent symptoms after concussion and provide an overview of assessment tools and management options.

Feature Editor IntroductionSurrogate decision making is a critical bioethical issuethat has been addressed by courts, policies, and medi-cal practices. Most states have laws that dictate towhom clinicians should go if a patient lacks the capacityto make decisions; in Illinois, for example, a hierarchi-cal list of surrogates guides clinicians in the absence of adurable power of attorney for health care. However, thecontext and complexities of family and surrogate re-lationships can make the process of surrogate decisionmaking very complicated. In fact, navigating psycho-logically and socially complex relationships that areunder stress as a result of a traumatic injury can lead toa host of ethical, moral, and sometimes legal issues forclinicians. The importance of this situation cannot beoverstated in the rehabilitation setting, which includesmany patients who do not have the capacity for complexdecision making.Over the years I have seen cases in which I doubtedthe surrogate’s capacity, as well as whether the surro-gate was acting on the patient’s beliefs or wishes or inthe patient’s best interest. However, the case framed inthis article brings up issues of complicated relation-ships, emotional reactions, feelings of split loyalties,and truth telling. Who defines or decides what is rightand wrong? What obligations do the treating team haveto different parties?In bioethics, truth telling is typically framed as anissue regarding clinicians’ sharing medical informationdfor example, HIV status or prognosis. In the followingscenario, which is an amalgamation of several cases, thetruth involves personal information that the patient hasnot told his family. It raises issues that highlight thecomplexities of working on a rehabilitation team, surro-gate decision making, and managing information.I have asked 5 respondents to comment on this case.Carol Levine, who directs the Families and Health CareProjectattheUnitedHospitalFundandisaFellowoftheHastings Center, discusses professional ethics and familydynamics.JeanneHoffman,arehabilitationpsychologistat the University of Washington and an expert in spinalcord injury rehabilitation, discusses the difference be-tween medical and personal information and the chang-ingrolesandbestinterestofthepatient.JasonByronandRobert Arnold, medical ethicists from the University ofPittsburgh,focusonthecoreethicalissues,tacklingthemfrom the perspectives of the patient, family, and careteam.Finally,AndyKondrat,abioethicist(andcolleague)attheRehabilitationInstituteofChicago,discussesmoraldistress in the context of team dynamics.If you have cases or topics you would like to proposefor future Ethical/Legal columns, please contact me atdmukherjee@ric.org. I welcome your feedback andcomments as well.Case ScenarioMr Jones, a 54-year-old man, was involved in a motorvehicle crash approximately 2 weeks ago and sustaineda spinal cord injury (SCI) and mild traumatic brain injury(TBI). He is currently an inpatient on the rehabilitationservice and has waxing and waning decisional capacityas a result of mild cognitive impairments. His wife of 23years is his surrogate decision maker for complex med-ical decisions. Mrs Jones has been at his bedside crying,and Mr Jones has told staff members that he feels guilty.During the course of treatment, it was revealed thatMr Jones was having an affair and was involved in theaccident when he was with his lover, Ann, who sustainedminimal injuries and was discharged from acute care.His wife believed he was out of town and was stunned toget a call from the hospital about the accident. WhileMr Jones was in a confused state, he called out for Ann,and his wife has become suspicious. Mrs Jones has beencoming in regularly to visit Mr Jones and has now beenasking the staff about what happened and who he waswith when he had the accident. She has restricted his

Objectives: To examine the prevalence of and clinical markers associated with mobility limitations in Medicare Current Beneficiary Community Survey (MCBS) respondents. Design: Cross-sectional analysis of a community survey. Setting: Community. Participants: Twelve thousand seven hundred sixty-nine respondents from the 2001 MCBS, aged 65 and older. Measurements: Four questions from the MCBS were used to create four levels of mobility limitation: none, mild, moderate, and severe. Sampling weights were used to calculate estimates of means and proportions of the entire Medicare population for each mobility limitation category. A polytomous logistic regression analysis was used to model the association between four levels of mobility limitation and sociodemographic and clinical variables. Results: Prevalence of mobility limitations ranged from 9.5 million (mild) to 1.2 million (severe). Increasing severity of mobility limitation was associated with older age, being female, reporting fair or poor health, being overweight, smoking, having a greater number of comorbidities, having an annual income below $25,000, having less than a high school education, being unmarried, and living with others. Conclusion: National prevalence estimates suggest that functional mobility limitation is a significant problem for many older adults and is associated with some potentially modifiable characteristics.

Chan L, Shumway-Cook A, Yorkston KM, Ciol MA, Dudgeon BJ, Hoffman JM. Design and validation of a methodology using the International Classification of Diseases, 9th Revision, to identify secondary conditions in people with disabilities. Objective To design and validate a methodology that identifies secondary conditions using International Classification of Disease, 9th Revision (ICD-9) codes. Design Secondary conditions were identified through a literature search and a survey of Washington State physiatrists. These conditions were translated into ICD-9 codes and this list was then validated against a national sample of Medicare survey respondents with differing levels of mobility and activities of daily living (ADL) disability. Setting National survey. Participants Participants (N=9731) in the 1999 Medicare Current Beneficiary Survey with no, mild, moderate, and severe mobility and ADL disability. Interventions Not applicable. Main outcome measure Percentage of survey respondents with a secondary condition. The secondary conditions were grouped into 4 categories: medical, psychosocial, musculoskeletal, and dysphagia related (problems associated with difficulty in swallowing). Results Our literature search and survey of 26 physiatrists identified 64 secondary conditions, including depression, decubitus ulcers, and deconditioning. Overall, 70.4% of all survey respondents were treated for a secondary condition. We found a significant relation between increasing mobility as well as ADL disability and increasing numbers of secondary conditions (χ 2 test for trend, P 2 test for trend, P 2 test for trend, P 2 test for trend, P 2 test for trend, P Conclusions We created a valid ICD-9–based methodology that identified secondary conditions in Medicare survey respondents and discriminated between people with different degrees of disability. This methodology will be useful for health services researchers who study the frequency and impact of secondary conditions.

Objective To describe the development of a telephone follow-up program that addresses the needs of survivors of traumatic brain injury (TBI) and their families in the year following injury. The process of developing the program is reviewed from the initial steps of identifying needs through final implementation of the program. Participants Eighty-four TBI survivors with moderate to severe injuries and their families. Results Descriptive statistics are presented including number of contacts, areas of concern for participants, and the types of interventions conducted. Case examples are provided to illustrate the impact of the telephone follow-up program. Conclusion This project demonstrated the feasibility of using the telephone as a means of providing information and support during the first year after moderate to severe traumatic brain injury. Telephone follow-up may enhance service provision for persons with TBI, especially those with a lack of transportation or geographic isolation.

To test the hypotheses that an educational program reduces the frequency and severity of urinary tract infections (UTIs) in persons with spinal cord injury (SCI) and impacts health beliefs, locus of control, and self-efficacy.Randomized controlled study.Fifty-six participants were randomized to patient educational program or control groups after a 5- or 6-month baseline period. The educational program group received written material on UTIs, a self-administered test, a review by nurse and physician, and a follow-up telephone call. Data were collected monthly throughout the baseline period and the 5- or 6-month follow-up period.The measures used were significant urine colony counts (UCCs), number of symptoms and UTIs, episodes of antibiotic treatment for UTIs, and 3 questionnaires (the Health Beliefs Questionnaire, the Multidimensional Health Locus of Control [MHLC] Scale, and a self-efficacy questionnaire).When controlling for baseline counts and the difference between groups at baseline, the treatment group had significantly fewer significant UCCs than did the control group (P = 0.009). A trend also was seen for fewer symptom reports (P = 0.094) and fewer number of antibiotic treatment episodes (P = 0.232) in the treatment group. In addition, whereas the treatment group tended to have higher scores on the internal MHLC Scale (P = 0.066), they also perceived the severity of UTIs as greater than did the control group (P = 0.042) and had lower scores on the self-efficacy questionnaire (P = 0.033).This is the first randomized controlled trial to demonstrate a significant reduction in bacterial load in the urine of persons with SCIs and an apparent reduction of symptoms and antibiotic treatment episodes for UTIs using a focused educational program. The increased scores on the internal MHLC Scale suggest that individuals in the treatment group felt that they had more control over their health behavior after receiving a UTI educational intervention.

To determine sensitivity, specificity, and positive and negative predictive values of nitrite (NIT) and leukocyte esterase (LE) testing in relation to laboratory evidence of significant bacteriuria and urinary tract infection (UTI) in persons with spinal cord injury (SCI).Monthly urine cultures were compared with results of dipstick testing.Community based.Fifty-six people with SCI were evaluated on a monthly basis with dipstick testing for NIT and LE as well as urine cultures. Participants reported whether they believed that they had a UTI and, if so, whether they were treated for the UTI and what symptoms they had experienced.The sensitivity rate for the most comprehensive criteria--defined as positive NIT test, a positive LE positive, or both a positive NIT test and positive LE test--was 0.64 and the specificity rate was only 0.52. No single type of bacteria was found to occur in more than 30% of the urine samples.Reliance on dipstick testing for NIT and LE in individuals with SCI can lead to high rates of overtreatment for UTI, given the fact that regular catheterization is associated with significant bacteriuria. Individuals with SCI should be evaluated with urine culture to ensure proper treatment.

Hoffman JM, Doctor JN, Chan L, Whyte J, Jha A, Dikmen S. Potential impact of the new Medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation. Arch Phys Med Rehabil 2003;84:1165–72. Objective: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. Design: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. Setting: Fourteen urban rehabilitation facilities throughout the United States. Participants: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). Interventions: Not applicable. Main Outcome Measures: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. Results: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. Conclusions: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.

A Monte Carlo study compared 14 methods to test the statistical significance of the intervening variable effect. An intervening variable (mediator) transmits the effect of an independent variable to a dependent variable. The commonly used R. M. Baron and D. A. Kenny (1986) approach has low statistical power. Two methods based on the distribution of the product and 2 difference-in-coefficients methods have the most accurate Type I error rates and greatest statistical power except in 1 important case in which Type I error rates are too high. The best balance of Type I error and statistical power across all cases is the test of the joint significance of the two effects comprising the intervening variable effect.

Objective To examine whether grief is a psychometrically sound construct that is distinct from depression in individuals who have recently sustained a spinal cord injury (SCI). Design Cross-sectional survey. Setting Inpatient rehabilitation units at 3 geographically diverse, university-affiliated medical centers. Participants Patients with SCI (N=206) were recruited (163 men [79.1%]). Most patients were non-Hispanic whites (n=175 [85.0%]). Most patients sustained a cervical SCI (n=134 [64.4%]). Various injury etiologies were represented, with the majority being accounted for by falls (n=72 [31.5%]) and vehicle-related accidents (n=69 [33.5%]). The mean time since injury was 53.5±40.5 days. Interventions Not applicable. Main Outcome Measures An adapted version of the 12-item structured clinical interview for Prolonged Grief Disorder was used to assess symptoms of grief, and the Patient Health Questionnaire-9 was used to measure depression. Demographic and injury-related data were also collected. Results A principal component analysis (with direct oblimin rotation) of the grief measure suggested a 2-component solution. The content of items loading on the separate components suggested 2 subscales: loss (6 items; Cronbach α=.810) and trauma (6 items; Cronbach α=.823). Follow-up principal component analyses including both grief and depression measures suggested clear differentiation of grief-related loss from depression. The prevalence of clinically significant levels of grief was low (6%), and levels of depression were consistent with previous findings related to inpatient rehabilitation (23.5%). Conclusions The items used to assess grief symptoms in patients participating in inpatient rehabilitation for recently sustained SCI appear to capture a psychometrically reliable construct that is distinct from that of depression. Research is needed on the predictive validity of early grief symptoms after SCI and the relation of grief to other psychological constructs over time.

Aims To test an educational programme with telephone follow-up to improve self-care in Brazilian patients who underwent percutaneous coronary intervention. Background Percutaneous coronary intervention has been established as a treatment for coronary disease. However, additional intervention is needed to improve self-care for individuals who undergo this procedure to reduce further disease. Telephone follow-up is one strategy that has been used to improve chronic disease self-care. Design Randomized controlled trial. Trial registration: ClinicalTrials.gov, NCT01341093. Methods Sixty patients who were preparing for their first percutaneous coronary intervention between 2011–2012 were randomly allocated to an educational programme with telephone follow-up (N = 30) or a control group (N = 30). Perceived health status was assessed with the Medical Outcomes Study 36-Item Short Form. Self-efficacy, symptoms of anxiety and depression and medication adherence were also assessed. Measures were collected before intervention (baseline) and 6 months later. Results Both groups improved from baseline to 6 months in the ‘Physical Component Summary’ and in the domains of ‘Physical Functioning’, ‘Role–Emotional’ and ‘Role–Physical’. The educational programme group showed a reduction in anxiety from baseline to 6-month follow-up, while the control group showed a slight increase. No differences in symptoms in depression and self-efficacy were found and both groups reported high levels of medication adherence. Conclusion The educational programme with telephone follow-up is a promising intervention as it led to reduction in anxiety for those receiving the educational programme. Further improvements in timing and focus of the educational programme, such as targeting emotional and social lifestyle changes, might be warranted.

Objective: To explore the relationship between headache trajectory across the first year after mild traumatic brain injury (mTBI) and the development of Post Traumatic Stress Disorder (PTSD) one year post-injury. Design: Longitudinal cohort. Setting: Community. Participants: 212 prospectively enrolled individuals diagnosed with mTBI. Interventions: None Main Outcome Measure(s): PTSD was measured by the PTSD ChecklistCivilian Version (PCL-C). Headache trajectories were determined by headache pain rating within 7 days of injury and at 3, 6, and 12 months post-injury. Results: Latent Class Trajectory analysis was used to identify 4 trajectories for headache after mTBI: Resolved (early headache that then went away NZ28), Worsening (limited early headache with increasing over time NZ63), Improving (significant early headache reducing steadily over time NZ23), and Chronic (significant headache across time NZ100). PTSD was found in 13% of the sample and was significantly associated with having a Chronic headache trajectory with 21 of 25 individuals with PTSD falling in this trajectory. Conclusions: The majority of individuals with mTBI had significant issues with headache over time, with most falling into the Worsening and Chronic trajectories, suggesting that early identification and treatment of headache may be important to change trajectory. In addition, having Chronic headache trajectory across the first year was also significantly associated with PTSD at one year after injury. Additional research is needed to determine how headache pain influences development of PTSD and/or how PTSD contributes to chronicity of headaches.

Objective. The effects of interpersonal stress on disease activity were examined for married women with rheumatoid arthritis (RA) who differ in the quality of their relationships with their spouses. Methods. Measures of interpersonal events were collected weekly for 12 weeks and related to disease activity through a comparison of clinician ratings and immune markers taken at baseline and during a highly stressful week for 20 RA patients. Individual differences in marital relationship variables and illness characteristics were used to predict group differences in how stress affected disease activity. Results. Significant elevations in total T cell activation (DR + CD3 cells), soluble interleukin-2 receptor (sIL-2R), and clinician's global ratings of disease activity were found during a week of significant interpersonal stress. However, women with better spousal relationships did not show increases in disease activity following an episode of interpersonal stress. In addition, patients taking low-dose prednisone showed greater reactivity to stress than patients not currently using glucocorticoid treatment. Conclusion. The results are consistent with the hypothesis that disease activity in RA increases following increases in interpersonal stress and that women with stronger marital relationships were less vulnerable to those stressors.

Objective: This study examined the effects of change in interpersonal stress on disease activity among 41 women with rheumatoid arthritis (RA). Methods: Measures of everyday stressful events and perceived stress were collected weekly for twelve weeks and related to disease activity in a series of pooled time-series regression analyses. Results: Increases in the number of interpersonal stressors in the same week and one week prior were associated with increases in disease activity. Pain from joint tenderness also was significantly related to a decrease in stressful events one week later. A subgroup of 20 patients showed a significant increase in interpersonal stress from baseline during the course of the study. For this group, significant elevations in DR+CD3 cells, sIL-2R, clinician's rating of disease, and self-reports of joint tenderness were found during the week of increased interpersonal stress. Conclusions: Interpersonal stress appears to be associated with increases in disease activity among RA patients

Disability is a dynamic process where functional status may change over time. Examination of the Medicare population suggests that, for those over age 65, disability status will fluctuate in 30% of beneficiaries each year. Less is known about those under age 65. The dynamic nature of disability is of relevance since it has important implications for social policies related to disability.To: (1) describe the characteristics of Medicare beneficiaries eligible due to disability; and (2) estimate the proportion of individuals with transitions in functional status over a one-year period stratified by baseline characteristics and diagnostic subgroups.We used the Medicare Current Beneficiary Survey from 1995 to 2005 to examine transitions in mobility and daily activities among individuals who were eligible for Medicare coverage due to disability.From the standpoint of function in mobility and daily activities, the working-age Medicare population with disability is fairly stable. While 75%-90% of our sample reported no disability or stable disability from one year to the next, depending on the condition and disability metric, as many as 13-14% of individuals showed improvement or decline in their functional status.In the working-age population with disability, a small percentage of individuals will improve or worsen from one year to the next. Since these transitions are associated with a variety of individual characteristics including health conditions, further research applied to larger samples is required to refine policy relevant models that might inform decisions related to ongoing eligibility for disability programs.

The purpose of this study is to evaluate the efficacy of a telephone-delivered cognitive behavioral treatment (T-CBT) in Veterans with a history of traumatic brain injury (TBI) for the treatment of chronic pain in a randomized controlled trial (RCT). Specifically, the RCT will examine the immediate (at the end of treatment) and long-term (6-months from randomization) efficacy of T-CBT on average pain intensity (primary outcome), and pain interference, sleep, depression, global impression of change, and life satisfaction (secondary outcomes) relative to a telephone-delivered pain psycho-educational active control condition (T-Ed). The study uses a 2-group parallel design. The sample will include 160 OEF/OIF Veterans with a history of TBI and chronic pain recruited from the VA Puget Sound Health Care System (VAPSHCS).Recruitment and enrollment for the study is ongoing. Despite the delays in recruitment and enrollment, we believe we will be able to achieve our enrollment goals given 1) the commitment by VAPSHCS providers to help us achieve our recruitment goals, and 2) the large number of VAPSHCS patients that we project to be eligible and willing to participate.

Objectives To describe the outcomes and lessons learned from a trial of telephone counseling (TC) to reduce medical complications and health care utilization and to improve psychosocial outcomes during the first year after spinal cord injury rehabilitation. Design Single-site, single-blind, randomized (1:1) controlled trial comparing usual care plus TC with usual care (UC). Setting Two inpatient rehabilitation programs. Participants Adult patients (N=168) discharged between 2007 and 2010. Interventions The TC group (n=85, 51%) received up to eleven 30- to 45-minute scheduled telephone calls to provide education, resources, and support. The UC group (n=83, 49%) received indicated referrals and treatment. Main Outcome Measures The primary outcome was a composite of self-reported health care utilization and medical complications. Secondary outcomes were depression severity, current health state, subjective health, and community participation. Results No significant differences were observed between TC and UC groups in the primary or secondary psychosocial outcomes. Conclusions This study had a number of strengths, but included potential design weaknesses. Intervention studies would benefit from prescreening participants to identify those with treatable problems, those at high risk for poor outcomes, or those with intentions to change target behaviors. Interventions focused on treatment goals and designed to work in collaboration with the participant's medical care system may lead to improved outcomes.

Background: Headache is a common and persistent symptom following traumatic brain injury (TBI). Headaches following TBI are defined primarily by their temporal association to injury, but have no defining clinical features. To provide a framework for treatment, primary headache symptoms were used to characterize headache. Methods: Three hundred and seventy-eight participants were prospectively enrolled during acute in-patient rehabilitation for TBI. Headaches were classified into migraine/probable migraine, tension-type, or cervicogenic headache at baseline and 3, 6, and 12 months following TBI. Results: Migraine was the most frequent headache type occurring in up to 38% of participants who reported headaches. Probable migraine occurred in up to 25%, tension-type headache in up to 21%, then cervicogenic headache in up to 10%. Females were more likely to have endorsed pre-injury migraine than males, and had migraine or probable migraine at all time points after injury. Those classified with migraine were more likely to have frequent headaches. Conclusions: Our data show that most headache after TBI may be classified using primary headache criteria. Migraine/probable migraine described the majority of headache after TBI across one year post-injury. Using symptom-based criteria for headache following TBI can serve as a framework from which to provide evidence-based treatment for these frequent, severe, and persistent headaches.

Hoffman JM, Donoso Brown E, Chan L, Dikmen S, Temkin N, Bell KR. Change in inpatient rehabilitation admissions for individuals with traumatic brain injury after implementation of the Medicare inpatient rehabilitation facility prospective payment system. Objective To evaluate the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on use of inpatient rehabilitation for individuals with traumatic brain injury (TBI). Design Retrospective cohort study of patients with TBI. Setting One hundred twenty-three level I and II trauma centers across the U.S. who contributed data to the National Trauma Data Bank. Participants Patients (N=135,842) with TBI and an Abbreviated Injury Score of the head of 2 or greater admitted to trauma centers between 1995 and 2004. Interventions None. Main Outcome Measure Discharge location: IRF, skilled nursing facility, home, and other hospitals. Results Compared with inpatient rehabilitation admissions before IRF PPS came into effect, demographic characteristics of admitted patients changed. Those admitted to acute care trauma centers after PPS was enacted (January 2002) were older and nonwhite. No differences were found in rates of injury between men and women. Over time, there was a significant drop in the percent of patients being discharged to inpatient rehabilitation, which varied by region, but was found across all insurance types. In a logistic regression, after controlling for patient characteristics (age, sex, race), injury characteristics (cause, severity), insurance type, and facility, the odds of being discharged to an IRF after a TBI decreased 16% after Medicare's IRF PPS system was enacted. Conclusions The enactment of the Medicare PPS appears to be associated with a reduction in the chance that patients receive inpatient rehabilitation treatment after a TBI. The impact of these changes on the cost, quality of care, and patient outcome is unknown and should be addressed in future studies.

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p

Hoffman JM, Dikmen S, Temkin N, Bell KR. Development of posttraumatic stress disorder after mild traumatic brain injury. Objective To examine the incidence of and factors associated with the development of posttraumatic stress disorder (PTSD) 6 months after civilian mild traumatic brain injury (MTBI). Design Secondary analysis of a randomized controlled trial of telephone follow-up versus usual care to reduce MTBI symptoms and improve function. Setting In-person and telephone interviews. Participants Prospectively studied participants (N=239) with MTBI enrolled in the emergency department. Interventions Not applicable. Main Outcome Measures Secondary analysis with main outcome measure of Posttraumatic Stress Disorder Checklist–Civilian Version. Results At 6 months after MTBI, 17% of participants met criteria for diagnosis of PTSD. Logistic regression predicting PTSD from baseline characteristics showed that participants who were Hispanic versus white, non-Hispanic and who, at the time of injury, described themselves as less happy and believed they would be more affected by their injury were significantly more likely to have PTSD. Conclusions Rates of PTSD in civilian MTBI in this study are consistent with prior research. Results suggest that personality characteristics and attribution regarding the injury may impact the development of PTSD. Early interventions addressing risk factors may prevent or reduce the likelihood of developing PTSD.

With the aging of the baby boomer population and their accompanying burden of disease, future disability rates are expected to increase. This paper summarizes the state of the evidence regarding physical activity and aging for individuals with mobility disability and proposes a healthy aging research agenda for this population. Using a previously published framework, we present evidence in order to compile research recommendations in four areas focusing on older adults with mobility disability: (1) prevalence of physical activity, (2) health benefits of physical activity, (3) correlates of physical activity participation, and, (4) promising physical activity intervention strategies. Overall, findings show a dearth of research examining physical activity health benefits, correlates (demographic, psychological, social, and built environment), and interventions among persons aging with mobility disability. Further research is warranted.

Hoffman JM, Bombardier CH, Graves DE, Kalpakjian CZ, Krause JS. A longitudinal study of depression from 1 to 5 years after spinal cord injury. Objective To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury. Design Longitudinal cohort study. Setting SCI Model System. Participants Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009. Interventions Not applicable. Main Outcome Measure Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher. Results Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found. Conclusion In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial.To test the hypotheses that hydrophilic catheters reduce the incidence of symptomatic urinary tract infections (UTIs) in persons with spinal cord injury on self-intermittent catheterization (IC).Randomized controlled trial.Community.Subjects (N=56) on IC with recurrent UTIs and who met eligibility criteria.Use of hydrophilic catheters for IC.Symptomatic UTIs treated with antibiotics.Of the 56 subjects enrolled, 45 completed the study (22 in the treatment group, 23 in the control group). There were no significant differences in demographics, including sex, between the treatment group and the controls except for more tetraplegic subjects in the control group (P.05). Seventy-one percent of the treatment group and 52% of the control group were men. The total number of symptomatic UTIs treated with antibiotics was significantly smaller in the treatment group than in the control group (P.05). Seventy percent of the control group had at least 1 antibiotic treatment episode compared with only 50% of those with the hydrophilic catheter (P=.18). There was no significant difference in the incidence of bacteriuria or symptomatic UTIs among the 2 groups. Level of injury and years with injury were unrelated to symptomatic UTIs, but being female increased the risk of UTIs (P.01).Although there was no difference in the number of symptomatic UTIs in the 2 groups, hydrophilic catheter usage was associated with reduced numbers of treated UTIs as compared with standard nonhydrophilic catheters in persons with spinal cord injury who used self-IC; however, the study is limited by a small sample size. Women on self-IC were more likely to develop UTIs regardless of the catheter type, suggesting that the benefits of the lubrication may be more important in men.

Objective To determine whether there are disparities in postacute stroke rehabilitation based on type of stroke, race/ethnicity, sex/gender, age, socioeconomic status, geographic region, or service area referral patterns in a large integrated health system with multiple levels of care. Design Cohort study tracking rehabilitation services for 365 days after acute hospitalization for a first stroke. Setting The Northern California Kaiser Permanente Health System (approximately 3.3 million membership population) Participants A total of 11,119 patients hospitalized for acute stroke from 1996 to 2003. The cohort includes patients discharged from acute care after a stroke. Postacute care rehabilitation services were evaluated according to the level of care ever-received within the 365 days after discharge from acute care, including inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health and outpatient, or no rehabilitation services. Interventions Not applicable. Main Outcome Measure Service delivery. Results Patients discharged to an IRH had longer lengths of stay in acute care. Patients with hemorrhagic stroke were less likely to be treated in an IRH. Patients whose highest level of rehabilitation was SNF were older and more likely to be women. After adjusting for age and other covariates, women were less likely to go to an IRH than men. Asian and black patients were more likely than white patients to be treated in an IRH or SNF. Also more likely to go to an IRH were patients from higher socioeconomic groups, from urban areas, and from geographic areas close to the regional rehabilitation hospital. Conclusions These results suggest variation in care delivery and extent of postacute care based on differences in patient demographics and geographic factors. Results also varied over time. Some minority populations in this cohort appeared to be more likely to receive IRH care, possibly because of disease severity, family support systems, cultural factors, or differences in referral patterns.

Dudgeon BJ, Hoffman JM, Ciol MA, Shumway-Cook A, Yorkston KM, Chan L. Managing activity difficulties at home: a survey of Medicare beneficiaries. Objective To describe assistance from helpers and use of assistive technology and environmental modification by community-dwelling people with difficulties in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Design Cross-sectional study using the 2004 Medicare Current Beneficiary Survey. Setting Community. Participants Nationally representative sample of 14,500 Medicare beneficiaries (mean age, 71.5y; 55% female; 49% currently married; 68% living with others; 84% white). Interventions Not applicable. Main Outcome Measures Self-reported difficulty with ADLs and IADLs; uses of help, assistive technology, and/or environmental modification. Results Difficulties were reported most frequently for heavy housework, walking, and shopping; money management, shopping, and light housework were reported as activities most often needing a helper. Walking, bathing, and toileting were activities most often needing uses of assistive technology. Bathroom modifications were the most commonly reported environmental modification. Results from a logistic regression showed that advancing age was the primary factor associated with increasing use of helpers and assistive technology or both for difficult activities. Conclusions Uses of helpers, assistive technology, and environmental modification are common but vary by type of ADL and/or IADL and age. Focused studies regarding uses of help and access to assistive technology and environmental modification appear needed to support community living. Public education about methods and types of accommodations appears needed and may substitute for or augment guidance from care providers.

Hoffman JM, Shumway-Cook A, Yorkston KM, Ciol MA, Dudgeon BJ, Chan L. Association of mobility limitations with health care satisfaction and use of preventive care: a survey of Medicare beneficiaries. Objective To examine the association between satisfaction with health care, the use of preventive health care, and mobility limitation. Design Cross-sectional analysis of survey data. Setting Community. Participants A total of 12,769 people, age greater than 65, who participated in the 2001 Medicare Current Beneficiary Survey. Interventions Not applicable. Main Outcome Measures Self-report of mobility limitation, satisfaction, and use of preventive health care (immunizations, cancer screening). Sampling weights were used in all analyses, including logistic regression for survey data, to calculate estimates for a Medicare population of 31 million. Results After controlling for sociodemographic characteristics, Medicare beneficiaries with mobility limitations were significantly more dissatisfied with their health care compared with beneficiaries without mobility limitations. Receipt of preventive care did not differ for those with and without mobility limitation on some preventive services. Conclusions Mobility limitation is highly associated with dissatisfaction with health care among older adult beneficiaries. Although Medicare beneficiaries may receive similar rates of preventive care, those with mobility limitation may have more difficulty accessing services and be more dissatisfied with their health care in general.

To examine the prevalence of and clinical markers associated with mobility limitations in Medicare Current Beneficiary Community Survey (MCBS) respondents.Cross-sectional analysis of a community survey.Community.Twelve thousand seven hundred sixty-nine respondents from the 2001 MCBS, aged 65 and older.Four questions from the MCBS were used to create four levels of mobility limitation: none, mild, moderate, and severe. Sampling weights were used to calculate estimates of means and proportions of the entire Medicare population for each mobility limitation category. A polytomous logistic regression analysis was used to model the association between four levels of mobility limitation and sociodemographic and clinical variables.Prevalence of mobility limitations ranged from 9.5 million (mild) to 1.2 million (severe). Increasing severity of mobility limitation was associated with older age, being female, reporting fair or poor health, being overweight, smoking, having a greater number of comorbidities, having an annual income below $25,000, having less than a high school education, being unmarried, and living with others.National prevalence estimates suggest that functional mobility limitation is a significant problem for many older adults and is associated with some potentially modifiable characteristics.

Bell KR, Temkin NR, Esselman PC, Doctor JN, Bombardier CH, Fraser RT, Hoffman JM, Powell JM, Dikmen S. The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: a randomized trial. Objective To measure the effectiveness of a scheduled telephone intervention offering counseling and education to people with traumatic brain injury (TBI) on behavioral outcomes compared with standard follow-up at 1 year postinjury. Design Two-group randomized, prospective clinical trial throughout the first year after injury. Setting Subjects' homes via telephone in an urban-rural catchment area from a level I trauma center. Participants Subjects (N=171; age range, 18–70y) with a primary diagnosis of TBI who were discharged from an acute rehabilitation unit. They were randomly assigned to the telephone intervention (n=85) or to standard follow-up (n=86) groups at discharge. Of these, 79 participated in the intervention and completed the outcome assessment (3 withdrew; 3 were lost to follow-up), and 78 participated in usual care and completed the outcome assessment (8 were lost to follow-up). Interventions Subjects were randomly assigned to receive telephone calls at 2 and 4 weeks and 2, 3, 5, 7, and 9 months after discharge. The calls consisted of brief motivational interviewing, counseling, and education, plus facilitating usual care or usual care alone through follow-up appointments and therapy prescriptions. Main outcome measures A composite outcome was used as the primary endpoint on an intent-to-treat basis. Secondary analyses were conducted with individual measures, including the FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Neurobehavioral Functioning Inventory, Functional Status Examination, Glasgow Outcome Scale–Extended, Medical Outcomes Study 36-Item Short-Form Health Survey, Brief Symptom Inventory, EuroQol, and Modified Perceived Quality of Life scale. The primary analysis was a blocked Mann-Whitney U test. Results At 1-year follow-up, those who had received scheduled telephone intervention fared significantly better on the primary composite outcome index ( P =.002). In addition, this group fared better on specific composites such as functional status ( P =.003) and quality of well-being ( P =.006). There were no significant differences on vocational status ( P =.08) or community integration status ( P =.13). Conclusions Scheduled telephone counseling and education resulted in improved overall outcome, particularly for functional status and quality of well-being, when compared with usual outpatient care. Telephone counseling shows promise as a low-cost, widely available rehabilitation intervention for TBI.

Understanding the use of weights in the analysis of data from multistage surveys. Large national surveys are powerful tools with which to examine a variety of important rehabilitation-related issues and are currently the only feasible method to study disability trends over time. Because it is impractical to draw simple random samples from the entire United States, national surveys, such as the Medicare Current Beneficiary Survey (MCBS), select random samples of subgroups of a population. Thus, respondents may have unequal probabilities of being included in the survey, and weighting must be used in the analysis before the results may be generalized to the entire United States. Surveys such as the MCBS are rich sources of data for rehabilitation medicine, and it can be expected that more research will be conducted using these data sources. Statistical analysis of these data should account for the sampling scheme used in data collection. We review the principles involved in the design of multistage samples, the calculation of weights, and their use in the data analysis, focusing on their importance in the estimation of population values. Our objective is to help readers to understand and interpret results of research articles using this methodology. Examples using the MCBS data are provided to clarify the concepts presented in the article.

Purpose: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfaction with medical care. Method: A total of 12,769 Medicare Current Beneficiary Survey respondents age 65 and older in 2001 were categorized by level of communication disability. Sampling weights were used to make inferences about the entire Medicare population. Results: Over 16 million beneficiaries reported a communication disability. Hearing problems were most commonly reported (41.99%). The association between dissatisfaction and communication disability was statistically significant ( p ≤ .05) for 8 of 10 items. Conclusions: Prevalence of dissatisfaction among those with a communication disability varied, ranging from 3.43% to 19.34%. Respondents with a communication disability reported much more dissatisfaction when compared with those respondents without a communication disability.

To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence.Survey design with analysis of cross-sectional data.Model Spinal Cord Injury Systems (MSCIS) centers.Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002.Not applicable.MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups.The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports.Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.

To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation.Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria.Fourteen urban rehabilitation facilities throughout the United States.Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807).Not applicable.Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes.The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients.Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.

The loss of autonomy that results from a disabling chronic illness is one of the most difficult and stressful experiences to cope with for an older adult. The ability lost is frequently never regained, and the older adult suffers from both the present loss and anticipation of a future of sustained and even increased confinement, both physical and psychological. As other investigators have found (see Zautra & Hempel, 1984, for a review), our research on older adults indicates that activity limitation has pervasive adverse effects on mental health (Reich & Zautra, 1988; Zautra, Guarnaccia, & Reich, 1988; Zautra, Reich, & Newsom, 1995). In comparison to those without impairment, older adults with functional loss often show more anxiety, more depression, less positive affect, and lower self-esteem (Reich & Zautra, 1988). The loss of autonomy due to chronic illness appears to lower one’s sense of personal control in general. Indeed, chronically ill adults show more fatalism, more helplessness (Smith & Wallston, 1992), and less perceived control over future events than do healthy controls (Lennon, Dohrenwend, Zautra, & Marbach, 1990).