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William Engelman,1 Flora M Hammond,2 James F Malec2 1Health Economics and Epidemiology, Evidera, Lexington, MA, 2Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA Abstract: Pseudobulbar affect (PBA) is defined by episodes of involuntary crying and/or laughing as a result of brain injury or other neurological disease. Epidemiology studies show that 5.3%–48.2% of people with traumatic brain injury (TBI) may have symptoms consistent with (or suggestive of) PBA. Yet it is a difficult and often overlooked condition in individuals with TBI, and is easily confused with depression or other mood disorders. As a result, it may be undertreated and persist for longer than it should. This review presents the signs and symptoms of PBA in patients with existing TBI and outlines how to distinguish PBA from other similar conditions. It also compares and contrasts the different diagnostic criteria found in the literature and briefly mentions appropriate treatments. This review follows a composite case with respect to the clinical course and treatment for PBA and presents typical challenges posed to a provider when diagnosing PBA. Keywords: traumatic brain injury, complications, differential diagnosis, crying, laughing

For many years, the mantra was that exercise had little or no effect on Parkinson's disease (PD). Few studies were conducted on PT/exercise and no progress was made in the area. It was feared that too much exercise would exacerbate the disease. Breakthroughs in the neurosciences suggest a host of factors, such as novelty, saliency, social factors, and repetitive task-oriented practice trigger plasticity-related events in the PD brain. Animal models of PD suggest intense sensorymotor training is neuroprotective. Although our understanding of the PD/exercise domain has improved, so has our appreciation for the complexity of the PD system. Yet, research in this area remains fragmented and the rehabilitation field is slow to implement new practices. Greater research partnerships between bench scientists and clinicians are needed. We must replicate research and form joint ventures with community organizations and test if our theories hold up at the community level. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To study cognitive, communication, and social changes experienced by individuals between 1 and 5 years after traumatic brain injury (TBI). DESIGN: Prospective cohort. SETTING AND PARTICIPANTS: TBI Model System Database with 927 eligible subjects using a cohort with complete 1- and 5-year data (N = 292). MAIN OUTCOME MEASURES: Change in Functional Independence Measure trade mark -Cognitive (FIM-Cog) items from Year 1 to Year 5 postinjury. RESULTS: On the FIM-Cog Total score, 26% individuals improved, 61% stayed the same, and 14% worsened by more than 1 point from Year 1 to Year 5. On the 2 FIM Communication items, 19% individuals improved, 68% stayed the same, and 13% worsened by greater than 1 point. On the FIM Social Interaction item, 12% individuals improved, 76% stayed the same, and 11% worsened. On the FIM Memory and Problem Solving items, 34% individuals improved, 48% stayed the same, and 19% worsened. Several variables predicted this improvement and worsening, some of which were available at the time of injury and most were those available at 1 year postinjury. The Memory and Problem Solving items, taken together, showed fewer participants at ceiling at Year 1 and more change between Year 1 and Year 5 compared to the Communication and Social Interaction items. CONCLUSIONS: Many individuals did not demonstrate meaningful change on FIM-Cog and its component items from Year 1 to Year 5. In particular, a high proportion of improvement was observed in Memory/Problem Solving, and worsening in Social Interaction. Demographic and functional indicators present at 1 year postinjury may be predictive of subsequent change. [ABSTRACT FROM AUTHOR]

Objective: The goal of this investigation was to pilot the Neuropsychiatric Inventory (NPI) among individuals with traumatic brain injury (TBI) and their caregivers, assessing its screen--metric approach. Design and Participants: Using the NPI, caregivers rated neurobehavioral disturbances in 51 individuals with moderate-to-severe TBI. The NPI was completed 1 or 2 years after the individuals were injured. Results: Caregivers reported the highest symptom levels for participants on Irritability/Lability, Apathy, and Agitation/Aggression, and rated greater levels of distress tied to those domains and to Dysphoria. Caregivers endorsing domain screening items endorsed significantly more metric items (vs. screen non-endorsers) within that domain, as would be expected if the screen accurately measured the psychopathology under consideration. In addition, the screen--metric yielded extremely low false-positive rates, although 5 of the 12 domains had elevated false-negative rates. Conclusions: Findings provide preliminary support for the accuracy of the NPI's screen--metric in this population and are consistent with prior work detailing common problematic neurobehavioral consequences of TBI. These results lay groundwork for research and clinical use of this measure in populations with TBI. [ABSTRACT FROM AUTHOR]

Objective: Traumatic brain injury (TBI) clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic complementary and integrative health (CIH) modalities, such as acupuncture for remediating pain. Barriers to delivering CIH modalities, such as acupuncture warrant examination. The objective of this study is to explore provider perspectives on challenges to accessing acupuncture treatment for chronic pain in persons with TBI and describe differences across health care settings. Setting: Civilian, Veterans Affairs (VA), and Department of Defense health care systems. Participants: Health care providers ( n = 145) were recruited from November 2022 to March 2023 via email through professional organizations and health care systems. Design: Descriptive cross-sectional self-report online survey. Main Measures: A survey assessed barriers using a 5-point Likert scale ( always a barrier to never a barrier ) using the Levesque Access to Care framework. Results: Of the 137 participants who provided information on setting, 86 (63%) worked in civilian health care; 47 (34%) worked in the Department of VA; and 4 (2.6%) in the Department of Defense (8 were missing data). Overall, providers endorsed all ten items as being barriers to accessing acupuncture treatment. However, these barriers were more statistically more frequently reported for civilian providers compared with VA providers for six of the 10 items, including lack of caregiver support ( p < 0.0001); own knowledge and understanding of the treatment ( p = 0.0025); health care setting culture discourages the treatment ( p = 0.0181); lack of qualified providers ( p = 0.0467); insurance does not cover ( p < 0.0001), and patient cannot afford ( p < 0.0001). VA provider respondents were more likely to answer all six items, as "Rarely/Never a Barrier," while providers in a civilian setting were more likely to respond "Always/Frequently" or "Sometimes" a barrier. Conclusion: Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. understanding barriers to delivering care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings.

Objective: To examine the efficacy of an intervention, Training to Reconnect with Emotional Awareness Therapy (TREAT) at improving alexithymia, emotion dysregulation, anxiety, depression, anger, and global positive and negative affect in participants with traumatic brain injury (TBI)., Design: Randomized, waitlist control (WLC) trial with 3-month follow-up., Setting: Outpatient brain injury rehabilitation center., Participants: Adult participants, who were on average 11.37 years postcomplicated mild-to-severe TBI and also had elevated alexithymia (n=44), who were randomized to immediate treatment (TREAT; n=20) or WLC (WLC=24)., Interventions: Eight sessions, structured training program that teaches emotional awareness and discrete labeling of emotions., Main Outcome Measures: Toronto Alexithymia Scale-20, Levels of Emotional Awareness Scale, Difficulty with Emotion Regulation Scale, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9; State-Trait Anger Expression Inventory (STAXI), Positive and Negative Affect Schedule (PANAS); and Patient Global Impression of Change., Results: Thirty-four participants completed the study per protocol. Compared with WLC participants (n=16) who had not yet received the intervention, TREAT participants (n=18) had significantly less alexithymia, emotion dysregulation, anxiety, and depression (all P's<.05) within approximately 1 week of completing the intervention. Before/after results from the pooled sample (n=34) showed significant improvements, immediately and 3 months after the intervention, on all outcomes except the STAXI and the Positive Affect subscale of the PANAS. On the Patient Global Impression of Change, a noticeable change in global emotional function and quality of life was reported by 80%. Intent-to-treat analyses (n=38) revealed similar results to the per protocol sample., Conclusions: Findings support the efficacy of TREAT for reducing alexithymia and emotion dysregulation in individuals with chronic TBI. Although outcomes were also promising for anxiety and depression, more research using attention-control designs are warranted to control for the attention received during treatment., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Preliminary examination of emotional awareness/expression relationships with pain in people with traumatic brain injury (TBI) and chronic pain (CP) and exploration of psychological factors as mediators or moderators of these relationships., Methods: Cross-sectional study in adults ( N  = 59) with chronic TBI and CP using Toronto Alexithymia Scale-20 Difficulty Identifying and Describing Feelings subscales; Ambivalence over Emotional Expressiveness Questionnaire; Emotional Approach Coping Scale; PROMIS Pain Intensity and Pain Interference scales, Michigan Body Map (pain widespreadness); headache frequency; Pain Catastrophizing Scale; Brief Symptom Inventory-18 (psychological distress), and Post-traumatic Stress Checklist-Civilian., Results: Difficulty Identifying Feelings was positively associated with pain intensity, pain interference, and headache frequency. Difficulty Describing Feelings was positively correlated with pain interference and headache frequency. Emotional Approach Coping was inversely correlated with headache frequency. Emotional awareness/expression relationships with pain outcomes were mediated by Pain Catastrophizing; Difficulty Describing Feelings relationships with Pain Interference and headache frequency were mediated by psychological distress; and Difficulty Describing Feelings associations with Pain Interference were mediated by post-traumatic stress. No moderators were identified., Conclusion: These preliminary findings suggest that emotional awareness/expression is linked to pain in adults with TBI and CP, which may be connected via pain catastrophizing and psychological distress. If longitudinal studies with larger samples produce similar findings, researchers should explore training emotional awareness/expression for possible pain management after TBI.

Many clinicians believe that residual impairments due to traumatic brain injury (TBI) are static once initial recovery has plateaued. That is, the effects of the injury are not expected to change significantly over the remainder of a person's life. This assumption has been called into question by several independent longitudinal studies showing that the long-term course of TBI may be better characterized as dynamic rather than static. Health care services that recognize brain injury as a chronic condition would encourage education on self-management to improve or protect health, as well as proactive health care that anticipates common co-morbidities. Those who have had a TBI would be encouraged to engage in lifestyles that optimize wellness. Almost all developed countries commit additional public health resources to addressing chronic conditions. In the United States, specific benefits are available from health insurance plans, particularly Medicare and Medicaid, for persons experiencing chronic health conditions. Potentially the most important benefit would derive from health care practitioners becoming aware of the dynamic nature of chronic brain injury and thus being more attentive to how their patients could be better served to optimize improvement and minimize decline. Recognition of TBI as a chronic condition would not only focus more resources on problems associated with living with brain injury but would also enhance both the public's and professionals' awareness of how to optimize the health and well-being of persons living with the effects of TBI.

Few studies have examined long-term mortality following traumatic brain injury (TBI) in a military population. This is a secondary analysis of a prospective, longitudinal study that examines long-term mortality (up to 10 years) post-TBI, including analyses of life expectancy, causes of death, and risk factors for death in service members and veterans (SM/V) who survived the acute TBI and inpatient rehabilitation. Among 922 participants in the study, the mortality rate was 8.3% following discharge from inpatient rehabilitation. The mean age of death was 54.5 years, with death occurring on average 3.2 years after injury, and with an average 7-year life expectancy reduction. SM/V with TBI were nearly four times more likely to die compared with the U.S. general population. Leading causes of death were external causes of injury, circulatory disease, and respiratory disorders. Also notable were deaths due to late effects of TBI itself and suicide. Falls were a significant mechanism of injury for those who died. Those who died were also more likely to be older at injury, unemployed, non-active duty status, not currently married, and had longer post-traumatic amnesia, longer rehabilitation stays, worse independence and disability scores at rehabilitation discharge, and a history of mental health issues before injury. These findings indicate that higher disability and less social supportive infrastructure are associated with higher mortality. Our investigation into the vulnerabilities underlying premature mortality and into the major causes of death may help target future prevention, surveillance, and monitoring interventions.

Purpose: To determine how life satisfaction changes across the first 10 years following traumatic brain injury (TBI)., Methods: Participants included 1,941 individuals from the TBI Model Systems database with life satisfaction data at 1-, 5-, and 10-years post-TBI. Based on Satisfaction With Life Scale scores, individuals were characterized as having one of the five 10-year life satisfaction trajectories: 'Stable High,' 'Stable Low,' 'Increased to High,' 'Decreased to Low,' and 'Unstable.' These were analyzed for group differences in demographics and psychosocial and functional outcomes., Results: Sixty percent participants had 'Stable High' or 'Increasing to High' trajectories. Approximately 25% had "Stable Low' or 'Decreasing to Low' trajectories, and approximately 15% had unstable trajectories. Higher life satisfaction trajectories were associated with the best psychosocial and functional outcomes whereas lower trajectories were associated with the worst psychosocial and functional outcomes. Trajectories were indistinguishable based on demographics., Conclusion: Life satisfaction over the first 10 years following TBI is dynamic, with most individuals reporting high life satisfaction by 10 years post-TBI. Examination of psychosocial and functional factors related to life satisfaction trajectories may inform community-based intervention recommendations, resources, and supports to maximize long-term satisfaction with life.

There is growing evidence that long-term outcomes after traumatic brain injury (TBI) are more dynamic than stable. People continue to change, both improving and declining, many years postinjury. Research, practice, and medical education have not yet fully embraced the implications of TBI as a chronic, dynamic condition. In 2020, the National Institute on Disability Independent Living and Rehabilitation Research funded the BeHEALTHY project to develop a model for long-term support of persons with chronic brain injury. Based on initial reviews of the available evidence and expert input from researchers, clinicians, and persons with lived experience, the BeHEALTHY model was proposed. Among existing chronic disease treatment models, Wagner's Chronic Care Model was selected as a starting point, with several critical refinements. The BeHEALTHY model endorses a person-centered approach, recognizing the individual with brain injury, and their social support system, as the primary source of goals in care planning. The model also acknowledges the critical importance of self-management and the need for health care programs to actively promote self-direction by the person using their social supports. The model also recognizes that outcomes are not determined solely by the person and the injury incurred but also by the environment in which a person lives and recovers. The importance of integrating health care with community resources is underscored by embracing environmental influences as a shared responsibility of the community and the health care system. This article recounts the impetus for developing the BeHEALTHY model and describes those it is intended to serve and its structural features and core components., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Alexithymia an emotional processing deficit that interferes with a person's ability to recognize, express, and differentiate emotional states. Study objectives were to (1) determine rates of elevated alexithymia among people with moderate-to-severe traumatic brain injury (TBI) 1-year post-injury, (2) identify demographic and injury-related variables associated with high versus low-average levels of alexithymia, and (3) examine associations among alexithymia with other aspects of emotional functioning and life satisfaction., Setting: Data were collected during follow-up interviews across four TBI Model System (TBIMS) centers., Participants: The sample consisted of 196 participants with moderate-to-severe TBI enrolled in the TBIMS. They were predominately male (77%), White (69%), and had no history of pre-injury mental health treatment (66.3%)., Design: Cross-sectional survey data were obtained at study enrollment and 1-year post-injury., Main Measures: Toronto Alexithymia Scale-20 (TAS-20) as well as measures of anger, aggression, hostility, emotional dysregulation, post-traumatic stress, anxiety, depression, resilience and life satisfaction. Sociodemographic information, behavioral health history and injury-related variables were also included., Results: High levels of alexithymia (TAS-20 score > 1.5 standard deviation above the normative mean) were observed for 14.3%. Compared to individuals with low/average levels of alexithymia, the high alexithymia group tended to have lower levels of education. At 1-year follow-up, high TAS-20 scores were strongly associated with emotional dysregulation and post-traumatic stress; moderately associated with anger, hostility, depression, anxiety, lower resilience and lower satisfaction with life; and weakly associated with aggression., Conclusion: These findings provide further evidence that alexithymia is associated with poor emotional functioning and life satisfaction after TBI. Longitudinal studies are needed to determine if alexithymia is a risk factor that precipitates and predicts worse emotional outcomes in the TBI population. This line of work is important for informing treatment targets that could prevent or reduce of psychological distress after TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years after injury., Design: Multicenter, longitudinal cohort study., Setting: Data were collected during year 1 and year 2 postinjury follow-up interviews across 4 TBI Model System centers., Participants: Persons with TBI (N=175; 134 men and 41 women) who had English fluency and were capable of providing self-reported data., Interventions: Not applicable., Main Outcome Measures: Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist - Civilian, Satisfaction with Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire 9, suicidal ideation, and problematic substance use., Results: Simple adjusted models demonstrated that after controlling for the specific outcome at year 1, Toronto Alexithymia Scale-20 scores significantly predicted year 2 scores for perspective-taking, physical aggression, emotional dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning., Conclusions: Compared with those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1 year after injury reported poorer emotional health at 2 years after TBI, even after controlling for year 1 outcome scores, sociodemographic characteristics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process., (Copyright © 2024 American Congress of Rehabilitation Medicine. All rights reserved.)

Objective: To describe the incidence of self-reported COVID-19 history in a longitudinal cohort of individuals with complicated mild to severe traumatic brain injury (TBI) and describe demographic, injury and functional differences based on history of COVID-19 infection., Design: Individuals with complicated mild to severe TBI aged 16 or older at time of injury who were enrolled in the TBI Model Systems longitudinal cohort study, completed a baseline or follow-up interview between October 1, 2021-March 31, 2023, and provided information about COVID-19 history and timing of COVID-19 infection was collected., Results: Of the 3,627 individuals included in the analysis, 29.5% reported a history of COVID-19 infection. Those with reported COVID-19 history tended to be younger, not of a racial/ethnic minority background, and greater functional status at follow up based on the Glasgow Outcome Scale-Extended scale compared to those with no reported COVID-19 history (p < 0.05). Among those with COVID-19 history, 61.8% did not receive medical care, 27.6% received medical care but no hospitalization, and 10.5% were hospitalized. Of those hospitalized, 21.4% required ventilator use., Conclusion: Incidence of COVID-19 diagnosis and related hospitalization characteristics in persons with complicated mild to severe TBI was similar to national incidence between March 2020-2023. Secondary effects of the COVID-19 pandemic on persons with TBI require investigation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults., Setting: Community., Participants: Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older., Design: Secondary data analysis of a large multicenter database., Main Measures: Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS)., Results: SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups., Conclusions: These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To quantify the benefits versus harms of amantadine in the treatment of irritability and aggression following traumatic brain injury., Methods: Secondary outcome data from a randomized controlled multisite trial of amantadine 100 mg twice daily were used to calculate number-needed-to-treat (NNT). Given prior findings of positive clinician-perceived effects and low incidence of adverse events, we hypothesized low number-needed-to-treat for benefit (NNTB; high benefit) and high number-needed-to-treat for harm (NNTH; low risk) based on the clinician ratings, supporting the use of amantadine in clinical practice. Specifically, NNTB values were calculated using number of individuals with improvement on the Clinician Global Impressions-Global Improvement scale (GI). NNTH values were computed using number of individuals with worsening on the GI and experiencing serious and any adverse events., Results: Based on clinician ratings, on average for every six patients treated with amantadine rather than placebo, one extra patient would be expected to improve (NNTB = 6.4; 95% confidence interval [CI]: [3.3-76.8]). More participants in the placebo group worsened than in the amantadine group, but the result was not statistically significant (NNTH = -92.4; 95% CI: [NNTB -32.9 to infinity to NNTH -19.2]). The amantadine and placebo groups did not differ on the numbers of adverse events experienced during the trial., Conclusion: Clinician ratings suggest modest benefit of amantadine 100 mg twice daily with low risk to appropriately selected patients with adequate renal clearance. Thus, amantadine should be considered a treatment option for the experienced brain injury clinician. These data may support treatment decisions when a pharmaceutical agent is being considered to control irritability/aggression., (© 2023 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.)

Background: The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC., Methods: The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms., Results: We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC., Conclusions: The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Importance: Guidelines recommend seizure prophylaxis for early posttraumatic seizures (PTS) after severe traumatic brain injury (TBI). Use of antiseizure medications for early seizure prophylaxis after mild or moderate TBI remains controversial., Objective: To determine the association between seizure prophylaxis and risk reduction for early PTS in mild and moderate TBI., Data Sources: PubMed, Google Scholar, and Web of Science (January 1, 1991, to April 18, 2023) were systematically searched., Study Selection: Observational studies of adult patients presenting to trauma centers in high-income countries with mild (Glasgow Coma Scale [GCS], 13-15) and moderate (GCS, 9-12) TBI comparing rates of early PTS among patients with seizure prophylaxis with those without seizure prophylaxis., Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) reporting guidelines were used. Two authors independently reviewed all titles and abstracts, and 3 authors reviewed final studies for inclusion. A meta-analysis was performed using a random-effects model with absolute risk reduction., Main Outcome Measures: The main outcome was absolute risk reduction of early PTS, defined as seizures within 7 days of initial injury, in patients with mild or moderate TBI receiving seizure prophylaxis in the first week after injury. A secondary analysis was performed in patients with only mild TBI., Results: A total of 64 full articles were reviewed after screening; 8 studies (including 5637 patients) were included for the mild and moderate TBI analysis, and 5 studies (including 3803 patients) were included for the mild TBI analysis. The absolute risk reduction of seizure prophylaxis for early PTS in mild to moderate TBI (GCS, 9-15) was 0.6% (95% CI, 0.1%-1.2%; P = .02). The absolute risk reduction for mild TBI alone was similar 0.6% (95% CI, 0.01%-1.2%; P = .04). The number needed to treat to prevent 1 seizure was 167 patients., Conclusion and Relevance: Seizure prophylaxis after mild and moderate TBI was associated with a small but statistically significant reduced risk of early posttraumatic seizures after mild and moderate TBI. The small absolute risk reduction and low prevalence of early seizures should be weighed against potential acute risks of antiseizure medications as well as the risk of inappropriate continuation beyond 7 days.

Objective: To describe the outcomes (change in functional independence and discharge disposition) of patients who after liver transplantation received acute inpatient rehabilitation in a freestanding rehabilitation hospital., Design: A retrospective chart review was conducted of patients admitted to an acute inpatient rehabilitation hospital within 6 months of undergoing liver transplantation between January 2014 and December 2018. Change in function from rehabilitation admission to discharge was measured using FIM Change and FIM Efficiency., Setting: A freestanding rehabilitation hospital., Participants: 107 patients who underwent acute inpatient rehabilitation at a freestanding rehabilitation hospital within 6 months after liver transplantation who met inclusion criteria (N=107). Most were men (71.96%), and the mean age of the patient population was 62.15 years., Interventions: Acute inpatient rehabilitation consisting of at least 3 hours of therapy 5 days a week split between physical therapy, occupational therapy, and speech language pathology services., Main Outcome Measure: FIM Change, FIM Efficiency, Discharge Disposition., Results: Participants were found to have statistically significant positive FIM Change ( P <.00001) and FIM Efficiency ( P <.00001). The mean FIM Change and Efficiency were 35.7±11.8 and 2.4±1.0, respectively. 83.2% (n = 89) were ultimately discharged to the community., Conclusion: Acute inpatient rehabilitation provides patients who have received a liver transplant with the opportunity to measurably improve their function and independence, with most patients being able to return home., (© 2024 The Authors.)

Objective: To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI., Design: An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI., Method: A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2)., Results: A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning., Conclusions: Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.)

Objective: To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI)., Methods: Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021., Eligibility Criteria: Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models., Data: Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use)., Synthesis: Narrative synthesis, including proportion of reviews documenting outcome benefits., Results: More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease., Conclusions: Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care., (© 2023 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.)

Computational neurosurgery is a novel and disruptive field where artificial intelligence and computational modeling are used to improve the diagnosis, treatment, and prognosis of patients affected by diseases of neurosurgical relevance. The field aims to bring new knowledge to clinical neurosciences and inform on the profound questions related to the human brain by applying augmented intelligence, where the power of artificial intelligence and computational inference can enhance human expertise. This transformative field requires the articulation of ethical considerations that will enable scientists, engineers, and clinical neuroscientists, including neurosurgeons, to ensure that the use of such a powerful application is conducted based on the highest moral and ethical standards with a patient-centric approach to predict and prevent mistakes. This declaration is a first attempt to draw a roadmap to guide the application of practical or applied ethics to computational neurosurgery. It is intended for the use of practitioners, ethicists, and scientists using artificial intelligence to understand and treat all the pathophysiological conditions related to the human brain., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Traumatic brain injury is the leading cause of death and disability worldwide. Despite this large impact, no predictive models are in widespread use due to tedious data collection requirements, lack of provider trust, and poor performance. Furthermore, these models use simple, often binary, data elements that fail to capture the complex heterogeneity of traumatic brain injury. Recent advances in computational modeling efforts have demonstrated promising results for capturing imaging, clinical, electroencephalographic, and other biomarkers for powerful predictive models. In this review, we provide an overview of efforts in computational modeling in neurotrauma and provide insights into future directions., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Objective: To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain., Setting: Community., Participants: A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up., Design: A multisite, cross-sectional observational cohort study., Main Outcome Measures: Functional outcomes, pain experience, and treatment., Results: 46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size., Conclusions: Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population., Setting: Community., Participants: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021., Design: Descriptive, qualitative study., Main Measures: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective., Results: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified., Conclusion: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported., Setting: Community., Participants: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021., Design: Descriptive, qualitative study., Main Measures: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective., Results: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types., Conclusion: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the relationship between extreme pain phenotypes (interference and improvement) and psychosocial outcomes among those with chronic pain after traumatic brain injury (TBI)., Setting: Community., Participants: In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain., Design: Multisite, cross-sectional, observational cohort study., Primary Measures: Life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation, the Brief Pain Inventory (BPI) interference scale, and the Patient's Global Impression of Change (PGIC)., Results: Persons in the extreme high interference phenotype (vs extreme low interference phenotype) and/or extreme no change phenotype (vs extreme improvement phenotype) had poorer psychosocial outcomes, with extreme pain interference phenotypes having a larger effect on outcomes than extreme perceived improvement phenotypes. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptoms (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality., Conclusions: Examination of extreme phenotypes provides important insights into the experience of individuals living with chronic pain and TBI. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes., Setting: Community., Participants: Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information., Design: Cross-sectional, secondary analysis from a multisite observational cohort., Main Outcome Measures: Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality., Results: Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated., Conclusions: Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes., Setting: Community., Participants: Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up., Design: Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations., Main Outcome Measures: Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years)., Results: The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI., Conclusions: Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain., Setting: Community., Participants: Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury., Design: Multisite, cross-sectional observational cohort study., Main Outcome Measures: Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation)., Results: Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06)., Conclusions: Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To define and characterize extreme phenotypes based on perceived improvement in pain for persons with chronic pain following traumatic brain injury (TBI)., Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers., Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview., Primary Measures: The Patient's Global Impression of Change (PGIC) related to pain treatment. Sociodemographic, injury, functional outcome, pain, and pain treatment characteristics., Results: Participants were mostly male (73%), White (75%), middle-aged (mean 46 years), injured in motor vehicle accidents (53%), or falls (20%). Extreme phenotypes were created for an extreme improvement phenotype ( n = 512, 29.8%) defined as "moderately better" or above on the PGIC and an extreme no-change group ( n = 290, 16.9%) defined as no change or worse. Least absolute shrinkage and selection operator (LASSO) regression combined with logistic regression identified multivariable predictors of improvement versus no-change extreme phenotypes. Higher odds of extreme improvement phenotype were significantly associated with being female (odds ratio [OR] = 1.85), married versus single (OR = 2.02), better motor function (OR = 1.03), lower pain intensity (OR = 0.78), and less frequent pain, especially chest pain (OR = 0.36). Several pain treatments were associated with higher odds of being in the extreme improvement versus no-change phenotypes including pain medication (OR = 1.85), physical therapy (OR = 1.51), yoga (OR = 1.61), home exercise program (OR = 1.07), and massage (OR = 1.69)., Conclusion: Investigation of extreme phenotypes based on perceived improvement with pain treatment highlights the ability to identify characteristics of individuals based on pain treatment responsiveness. A better understanding of the biopsychosocial characteristics of those who respond and do not respond to pain treatments received may help inform better surveillance, monitoring, and treatment. With further research, the identification of risk factors (such as pain intensity and frequency) for treatment response/nonresponse may provide indicators to prompt changes in care for individuals with chronic pain after TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.

Objective: To define and characterize extreme phenotypes based on pain interference for persons with chronic pain following traumatic brain injury (TBI)., Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers., Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview., Primary Measures: The Brief Pain Inventory (BPI) interference scale, sociodemographic, injury, functional outcome, pain, and treatment characteristics., Results: Participants were predominantly male (73%), White (75%), middle-aged (mean 46 years), and who were injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25th percentiles to create low-interference ( n = 441) and high-interference ( n = 431) extreme phenotypes. Bivariate comparisons found several sociodemographic, injury, function, pain, and treatment differences between extreme phenotype groups, including significant differences ( P < .001) on all measures of concurrent function with those in the low-interference extreme phenotype experiencing better function than those in the high-interference extreme phenotype. Lasso regression combined with logistic regression identified multivariable predictors of low- versus high-interference extreme phenotypes. Reductions in the odds of low- versus high-interference phenotypes were significantly associated with higher pain intensity (odds ratio [OR] = 0.33), having neuropathic pain (OR = 0.40), migraine headache (OR = 0.41), leg/feet pain (OR = 0.34), or hip pain (OR = 0.46), and more pain catastrophizing (OR = 0.81)., Conclusion: Results suggest that for those who experience current chronic pain, there is high variability in the experience and impact of pain. Future research is needed to better understand how pain experience impacts individuals with chronic pain and TBI given that pain characteristics were the primary distinguishing factors between phenotypes. The use of extreme phenotypes for pain interference may be useful to better stratify samples to determine efficacy of pain treatment for individuals with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: It is not currently possible to predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Our objective was to fit and externally validate a prediction model for 1-year dependency in patients with DoC ≥ 2 weeks after TBI., Methods: We included adults with TBI enrolled in TBI Model Systems (TBI-MS) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) studies who were not following commands at rehabilitation admission or 2 weeks post-injury, respectively. We fit a logistic regression model in TBI-MS and validated it in TRACK-TBI. The primary outcome was death or dependency at 1 year post-injury, defined using the Disability Rating Scale., Results: In the TBI-MS Discovery Sample, 1,960 participants (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria, and 406 (27%) were dependent 1 year post-injury. In a TBI-MS held out cohort, the dependency prediction model's area under the receiver operating characteristic curve was 0.79 (95% CI 0.74-0.85), positive predictive value was 53% and negative predictive value was 86%. In the TRACK-TBI external validation (n = 124, age 40 [16] years, 77% male, 81% white), the area under the receiver operating characteristic curve was 0.66 (0.53, 0.79), equivalent to the standard IMPACT core + CT score (p = 0.8)., Interpretation: We developed a 1-year dependency prediction model using the largest existing cohort of patients with DoC after TBI. The sensitivity and negative predictive values were greater than specificity and positive predictive values. Accuracy was diminished in an external sample, but equivalent to the IMPACT model. Further research is needed to improve dependency prediction in patients with DoC after TBI. ANN NEUROL 2023;94:1008-1023., (© 2023 American Neurological Association.)

Objective: To identify demographic, injury-related, and 1-year postinjury clinical and functional predictors of high and low life satisfaction at 10 years after moderate to severe traumatic brain injury (TBI) using an extreme phenotyping approach., Setting: Multicenter longitudinal database study., Participants: A total of 3040 people from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems database with life satisfaction data at 10 years post-TBI., Design: Multicenter, cross-sectional, observational design., Main Measures: Satisfaction With Life Scale (outcome), Glasgow Coma Scale, Disability Rating Scale, Functional Independence Measure, Participation Assessment with Recombined Tools-Objective, Patient Health Questionnaire-9, and General Anxiety Disorder-7 (standardized predictors)., Results: Greater cognitive and motor independence, more frequent community participation, and less depressive symptoms 1 year post-moderate to severe TBI predicted extreme high life satisfaction 10 years later. Non-Hispanic White and Hispanic individuals were significantly more likely than Black individuals to have extreme high life satisfaction 10 years post-TBI., Conclusions: Extreme phenotyping analysis complements existing knowledge regarding life satisfaction post-moderate to severe TBI. From a chronic disease management perspective, future studies are needed to examine the feasibility and impact of early postinjury medical and rehabilitative interventions targeting cognitive and motor function, community participation, and mood on the maintenance/enhancement of long-term life satisfaction post-TBI., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate whether a functional decline in cognitive activities decades after moderate-to-severe traumatic brain injury (m-sTBI) might relate to injury features and/or lifetime health factors, some of which may emerge as consequences of the injury., Design: Secondary analysis of the TBI Model Systems National Database, a prospective, multi-center, longitudinal study of patients with m-sTBI., Setting: TBI Model Systems Centers., Participants: Included were 732 participants rated on the cognitive subscale of the Functional Independence Measure (FIM Cognitive), a metric for everyday cognitive skills, across 3 time points out to 20 years (visits at 2-, 10-, and 20-year follow-ups; N=732)., Interventions: Not applicable., Main Outcome Measure(s): FIM Cognitive Scale. Injury characteristics such as timing and features pertaining to severity and health-related factors (eg, alcohol use, socioeconomic status) were examined to discriminate stable from declining participants on the FIM Cognitive Scale using logistic regression., Results: At 20 years post-injury, there was a low base rate of FIM Cognitive decline (11%, n=78), with most being stable or having meaningful improvement (89%, n=654). Older age at injury, longer duration of post-traumatic amnesia, and presence of repetitive seizures were significant predictors of FIM Cognitive decline in the final model (area under the curve=0.75), while multiple health-related factors that can represent independent co-morbidities or possible consequences of injury were not., Conclusion(s): The strongest contributors to reported functional decline in cognitive activities later-in-life were related to acute characteristics of m-sTBI and experiencing post-traumatic seizures. Future studies are needed integrating functional with performance-based cognitive assessments to affirm conclusions and identify the timeline and trajectory of cognitive decline., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose/objective: Examine contributors to resilience among caregivers of individuals who have sustained a moderate-to-severe traumatic brain injury (TBI), with the goal of identifying important targets for an intervention to improve caregiver resilience as well as outcomes for people with TBI., Research Method/design: Participants were adult caregivers ( n = 176) and individuals with TBI who required inpatient rehabilitation at six TBI Model System sites. Measures included the Connor-Davidson Resilience Scale-10, Family Needs Questionnaire, Zarit Burden Interview, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected between September 2018 and June 2021., Results: Caregivers endorsed levels of personal resilience that were comparable to norms for community samples and slightly higher than groups under stress or with medical illness. Reports of the burden associated with the caregiving role were relatively low, as was reported psychological distress. In a multivariable model, higher proportions of met emotional support needs were associated with increased resilience., Conclusions/implications: Resilience may be strengthened by emotional support networks, including friends or family who may not already be directly involved in the provision of care. Supporting engagement with community agencies, peer mentors, or other informal resources within the family system that provide emotional support may bolster resilience outcomes for caregivers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objectives: The objective of this study was to understand the relative contribution of acute motor versus cognitive functioning on community integration 1 year after moderate-severe traumatic brain injury (TBI)., Methods: Secondary data analysis of 779 participants in the TBI Model Systems National Database who experienced a moderate-severe TBI requiring inpatient rehabilitation. Participants were categorized into four groups: low motor/low cognition, low motor/high cognition, high motor/low cognition, or high motor/high cognition. Community integration outcomes measured 1 year post-TBI included the Participation Assessment with Recombined Tools-Objective (PART-O), driving status, Supervision Rating Scale, residence, re-injury, and employment status., Results: Participants with both high motor/high cognition had higher scores on the PART-O total score ( p  < 0.001), living independently ( p  = 0.023), living in a private residence ( p  = 0.002), and being employed ( p  = 0.026) at 1 year. Participants with high motor/high cognition and high motor/low cognition had higher odds of driving ( p  = 0.001 and p  = 0.034, respectively) when compared to low motor/low cognition. All groups relative to the low motor/low cognition group had higher odds of being re-injured., Discussion and Conclusions: High motor and high cognitive function at rehabilitation are associated with favorable community integration outcomes 1 year post-injury, though greater participation afforded by high function may confer elevated risk of re-injury.