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OBJECTIVE: Report a case of severe self-injurious behavior (SIB), paying special attention to treatment. DESIGN: Case report. PARTICIPANT: A 26-year-old woman (H.S.) 8 years post-traumatic brain injury with a history of severe SIB. METHODS: H.S. was treated over a 22-week period with combined behavioral and psychopharmacological interventions. RESULTS: Marked reduction in SIB was noted after the interventions were initiated. CONCLUSION: Behavioral treatment and medications may be useful tools in the treatment of SIB after traumatic brain injury. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Investigate the impact of race on productivity outcome after traumatic brain injury (TBI) and evaluate the influence of confounding factors on this relationship. DESIGN: Inception cohort of 1083 adults with TBI for whom 1-year productivity follow-up data were available. RESULTS: Univariable logistic regression indicated that race was a significant predictor of productivity outcome after TBI. African Americans were 2.76 times more likely to be nonproductive than whites and other racial minorities were 1.92 times more likely to be nonproductive than whites. Multivariable logistic regression analyses revealed that the effect of race on employability was influenced by confounds with preinjury productivity, education level, and cause of injury. After adjustment for other predictors, African Americans were 2.00 times more likely to be nonproductive than whites and other racial minorities were 2.08 times more likely to be nonproductive than whites. The multivariable logistic regression model with all predictors except race accounted for 39% of the variability in productivity outcome (R2-Nagelkerke=0.39), whereas the full logistic regression model including race accounted for 41% of the variability in productivity outcome (R2-Nagelkerke=0.41); a difference of only 2%. CONCLUSION: Any effect of race on productivity is significantly influenced by confounding with preinjury productivity, education level, and cause of injury. [ABSTRACT FROM AUTHOR]

Objective: To comprehensively estimate the diagnostic accuracy and reliability of the Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Clinical Reminder Screen (TCRS)., Design: Cross-sectional, prospective, observational study using the Standards for Reporting of Diagnostic Accuracy criteria., Setting: Three VA Polytrauma Network Sites., Participants: Operation Iraqi Freedom, Operation Enduring Freedom veterans (N=433)., Main Outcome Measures: TCRS, Comprehensive TBI Evaluation, Structured TBI Diagnostic Interview, Symptom Attribution and Classification Algorithm, and Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale., Results: Forty-five percent of veterans screened positive on the TCRS for TBI. For detecting occurrence of historical TBI, the TCRS had a sensitivity of .56 to .74, a specificity of .63 to .93, a positive predictive value (PPV) of 25% to 45%, a negative predictive value (NPV) of 91% to 94%, and a diagnostic odds ratio (DOR) of 4 to 13. For accuracy of attributing active symptoms to the TBI, the TCRS had a sensitivity of .64 to .87, a specificity of .59 to .89, a PPV of 26% to 32%, an NPV of 92% to 95%, and a DOR of 6 to 9. The sensitivity was higher for veterans with PTSD (.80-.86) relative to veterans without PTSD (.57-.82). The specificity, however, was higher among veterans without PTSD (.75-.81) relative to veterans with PTSD (.36-.49). All indices of diagnostic accuracy changed when participants with questionably valid (QV) test profiles were eliminated from analyses., Conclusions: The utility of the TCRS to screen for mild TBI (mTBI) depends on the stringency of the diagnostic reference standard to which it is being compared, the presence/absence of PTSD, and QV test profiles. Further development, validation, and use of reproducible diagnostic algorithms for symptom attribution after possible mTBI would improve diagnostic accuracy., (Published by Elsevier Inc.)

Objective: The aim of this study was to describe the association between mild traumatic brain injury (mTBI) and persisting postconcussive symptoms according to symptom category, number, and severity., Design: The study design was observational., Participants: The study sample comprised veterans (≥18 years of age) deployed in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts who had not received any treatment for mTBI in the 30 days preceding study enrollment., Methods: Veterans were interviewed and completed testing in a single day. The Standard TBI Diagnostic Interview and the Clinician-Administered PTSD Scale were used. Testing included the Neurobehavioral Symptom Inventory and a full neuropsychological battery. Gold standard classification methods were utilized to determine presence/absence of mTBI. For each of the 5 symptom outcomes, an adjusted multiple linear regression model (negative binomial count models) accounting for effects of socio-demographic variables and behavioral health conditions was used., Main Outcome Measures: Self-report of neurobehavioral symptoms categorized as affective, cognitive, somatic, and vestibular symptoms, in addition to the instruments specified above., Results: OEF/OIF veterans with mTBI, relative to veterans with no mTBI, were observed to have 30% more symptoms overall (P < .001), 34% more somatic symptoms (P < .001), 22% more cognitive symptoms (P = .008), 15% more affective symptoms (P = .017), and 59% more vestibular symptoms (P < .001). For adjusted models, variables significantly related to number of symptoms across all 4 symptom categories were anxiety (all P < .001) and insomnia (all P < .001). For the adjusted models, variables significantly related to symptom severity across all 4 symptom categories were insomnia (all P < .001), depression (P < .001-.05) and anxiety (all, P < .001)., Conclusions: OEF/OIF veterans with mTBI, relative to veterans with no mTBI, have significantly more and significantly more severe persisting symptoms, with vestibular symptoms reported with the greatest frequency. After accounting for behavioral health conditions and socio-demographic factors, OEF/OIF veterans with mTBI compared to veterans without mTBI had significantly more cognitive, affective, vestibular, and somatic symptoms persisting 4.8 years after the mTBI event(s)., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

United States veterans of the Iraqi (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) conflicts have frequently returned from deployment after sustaining mild traumatic brain injury (mTBI) and enduring stressful events resulting in post-traumatic stress disorder (PTSD). A large number of returning service members have been diagnosed with both a history of mTBI and current PTSD. Substantial literature exists on the neuropsychological factors associated with mTBI and PTSD occurring separately; far less research has explored the combined effects of PTSD and mTBI. The current study employed neuropsychological and psychological measures in a sample of 251 OIF/OEF veterans to determine whether participants with a history of mTBI and current PTSD (mTBI+PTSD) have poorer cognitive and psychological outcomes than participants with mTBI only (mTBI-o), PTSD only (PTSD-o), or veteran controls (VC), when groups are comparable on intelligence quotient, education, and age. The mTBI+PTSD group performed more poorly than VC, mTBI-o, and PTSD-o groups on several neuropsychological measures. Effect size comparisons suggest small deleterious effects for mTBI-o on measures of processing speed and visual attention and small effects for PTSD-o on measures of verbal memory, with moderate effects for mTBI+PTSD on the same variables. Additionally, the mTBI+PTSD group was significantly more psychologically distressed than the PTSD-o group, and PTSD-o group was more distressed than VC and mTBI-o groups. These findings suggest that veterans with mTBI+PTSD perform significantly lower on neuropsychological and psychiatric measures than veterans with mTBI-o or PTSD-o. The results also raise the possibility of mild but persisting cognitive changes following mTBI sustained during deployment.

Objectives: To synthesize evidence and report findings from a systematic search and descriptive analysis of peer-reviewed published evidence of the accuracy of tests used for diagnosing mild traumatic brain injury (mTBI). The article also summarizes points of concurrence and divergence regarding case definitions of mTBI identified during the review. TYPE: Systematic review and descriptive analysis of published evidence., Literature Survey: A search of PubMed, PsychInfo, and the Cochrane Library for peer-reviewed publications between 1990 and July 6, 2011, identified 1218 abstracts; 277 articles were identified for full review, and 13 articles met the criteria for evaluation., Methodology: Manuscript inclusion criteria were (1) reported sensitivity (Se) and specificity (Sp), or reported data were sufficient to compute Se and Sp; (2) >1 participant in the study; (3) at least 80% of the study cohort was ≥18 years of age; and (4) written in English. Articles describing clinical practice guidelines, opinions, theories, or clinical protocols were excluded. Seven investigators independently evaluated each article according to the Standards for Reporting of Diagnostic Accuracy (STARD) criteria., Synthesis: Findings indicate that all 13 studies involved civilian noncombat populations. In 7 studies, authors examined acute mTBI, and in 4 studies, historical remote mTBI was examined. In the 13 studies, Se ranged from 13%-92% and Sp ranged from 72%-99%, but confidence in these findings is problematic because the STARD review indicates opportunities for bias in each study., Conclusions: Findings indicate that no well-defined definition or clinical diagnostic criteria exist for mTBI and that diagnostic accuracy is currently insufficient for discriminating between mTBI and co-occurring mental health conditions for acute and historic mTBI. Findings highlight the need for research examining the diagnostic accuracy for acute and historic mTBI., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

The Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-RF) validity scales were evaluated to determine accuracy when differentiating honest responding, random responding, genuine posttraumatic stress disorder (PTSD), and feigned PTSD. Undergraduate students (n = 109), screened for PTSD, were randomly assigned to 1 of 4 instructional groups: honest, feign PTSD, half random, and full random. Archival data provided clinical MMPI-2-RF profiles consisting of 31 veterans diagnosed with PTSD. Veterans were diagnosed with PTSD using a structured interview and had passed a structured interview for malingering. Validity scales working as a group had correct classification rates of honest (96.6%), full random (88.9%), genuine PTSD (80.7%), fake PTSD (73.1%), and half random (44.4%). Results were fairly supportive of the scales' ability to discriminate feigning and full random responding from honest responding of normal students as well as veterans with PTSD. However, the RF validity scales do not appear to be as effective in detecting partially random responding.

Current combat veterans are exposed to many incidents that may result in mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). While there is literature on the neuropsychological consequences of PTSD only (PTSD-o) and mTBI alone (mTBI-o), less has been done to explore their combined (mTBI+PTSD) effect. The goal of this study was to determine whether Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans with mTBI+PTSD have poorer cognitive and psychological outcomes than veterans with PTSD-o, mTBI-o, or combat exposure-only. The final sample included 20 OIF/OEF veterans with histories of self-reported deployment mTBI (mTBI-o), 19 with current PTSD (PTSD-o), 21 with PTSD and self-reported mTBI (mTBI+PTSD), and 21 combat controls (CC) (no PTSD and no reported mTBI). Groups were formed using structured interviews for mTBI and PTSD. All participants underwent comprehensive neuropsychological testing, including neurocognitive and psychiatric feigning tests. Results of cognitive tests revealed significant differences in performance in the mTBI+PTSD and PTSD-o groups relative to mTBI-o and CC. Consistent with previous PTSD literature, significant differences were found on executive (switching) tasks, verbal fluency, and verbal memory. Effect sizes tended to be large in both groups with PTSD. Thus, PTSD seems to be an important variable affecting neuropsychological profiles in the post-deployment time period. Consistent with literature on civilian mTBI, the current study did not find evidence that combat-related mTBI in and of itself contributes to objective cognitive impairment in the late stage of injury.

There are scant prospective studies defining improvements in critical outcome measures with hormone replacement in hypopituitarism secondary to brain injury. We review the tests of cognition and physical function and summarize their use for subjects that are deficient in anterior hormone production during anterior pituitary hormone replacement in brain injury and propose these as the minimal tests that are feasible for a physician to perform in a clinical setting. We summarize the studies conducted to assess outcome measures after brain injury and also report preliminary findings for improvements in cognition and physical function in subjects with brain injury and GH deficiency.

Objective: The diagnosis of growth hormone deficiency (GHD) in adults is established through growth hormone (GH) stimulation testing, which is often complex, expensive, time-consuming and may be associated with adverse side effects. The decision to perform GH provocative testing is influenced by clinical findings, medical history and biochemical evidence. We report in this study our experience using the glucagon stimulation test (GST) in assessing GHD in adult patients with traumatic brain injury (TBI) as it relates to baseline serum insulin-like growth factor-1 (IGF-1) concentrations., Design: A receiver operating characteristic (ROC) curve analysis was performed to determine the optimal IGF-1 cut-off for diagnosis of GHD at different potential diagnostic GST cut-off values (<3, <5, & <10 μg/l)., Patients: One hundred and thirty-eight patients (98 men and 40 women) with a documented history of moderate to severe TBI were assessed for GHD using serum IGF-1 concentrations and the GST., Measurements: IGF-1 values were compared with peak GH values obtained following the GST., Results: An IGF-1 cut-off value of 175 μg/l minimized the misclassification of GHD patients and GH-sufficient patients and provided a sensitivity of 83% and specificity of 40%, as well as a negative predictive power of 90% considering a criterion for peak GH response of <3 μg/l., Conclusions: Our current findings are consistent with previous work assessing peak GH response using the insulin tolerance test (ITT) in a non-TBI sample, suggesting that diagnostic accuracy may be optimized if the GST is used when obtained serum IGF-1 concentrations are below 175 μg/l. While the decision to perform provocative testing to assess GHD in adult patients should be based on the clinician's clinical impression, the findings from this retrospective study can provide useful clinical information and serve as a guide., (© 2011 Blackwell Publishing Ltd.)

Traumatic brain injury (TBI) is a major public health issue, and yet medical science has little to offer for the persistent symptoms that prevent many of these individuals from fully re-entering society. Post-traumatic hypopituitarism, and specifically growth hormone deficiency (GHD), has been found in a large percentage of individuals with chronic moderate to severe TBI. Presently, there are no published treatment studies of hormone replacement in this population. In this study, 83 subjects with chronic TBI were screened for hypopituitarism. Forty-two subjects were found to have either GHD or GH insufficiency (GHI), of which 23 agreed to be randomized to either a year of GH replacement or placebo. All subjects completed the study with no untoward side effects from treatment. A battery of neuropsychological tests and functional measures were administered before and after treatment. Improvement was seen on the following tests: Dominant Hand Finger Tapping Test, Wechsler Adult Intelligence Scale III-Information Processing Speed Index, California Verbal Learning Test II, and the Wisconsin Card Sorting Test (executive functioning). The findings of this pilot study provide preliminary evidence suggesting that some of the cognitive impairments observed in persons who are GHD/GHI after TBI may be partially reversible with appropriate GH replacement therapy.

Objective: To assess the effects of growth hormone (GH) replacement in an individual who sustained mild traumatic brain injury (mTBI) as an adult and was found to have GH deficiency by glucagon stimulation testing., Participant: A 43-year old woman who sustained a mild TBI at age 37 years. She was 6.8 years post-injury when she began supplementation., Intervention: Recombinant human GH (rhGH) subcutaneously per day for 1 year., Main Outcome Measures: Single fibre muscle function was evaluated from muscle biopsies. Body composition, muscle strength and peak aerobic capacity were also measured. In addition, neuropsychological tests of memory, processing speed and motor dexterity and speed, as well as a self-report depression inventory were administered. All assessments were performed at baseline and after 6 and 12 months of rhGH replacement therapy., Results: Single muscle fibre changes were greatest at 6 months. Body composition showed continuous improvement. Muscle strength improved for knee extension. Peak oxygen consumption increased at 6 months and total work and ventilatory equivalents continued to improve at 12 months. Significant improvements in neuropsychological test performance were not found, with the exception of performance on a test of motor dexterity and speed., Conclusion: rhGH replacement in a subject with GH deficiency after mild TBI improves muscle force production, body composition and aerobic capacity. Reliable improvements on tests of cognition were not found in this subject.

Objective: To compare errorless learning with trial-and-error (T&E) learning of declarative facts in children with memory disorders secondary to traumatic brain injury (TBI)., Design: Retrospective within-subjects concurrent treatment design., Setting: Participants' school or home., Participants: Thirty-four children, ages 6 to 18 years, with mild, moderate, or severe postacute TBI who met criteria for memory impairment., Intervention: Conditions consisted of an errorless learning method and a T&E method. Within a session, half the items were taught with the errorless learning method and half with the T&E method. Each child received two 1-hour sessions a week for 7 weeks., Main Outcome Measures: Relative effectiveness of errorless learning and T&E methods for (1) initial learning and (2) retention over time for learned items., Results: There was an advantage for T&E on initial learning. In children with mild, but not moderate or severe TBI, 2-day retention was better with the errorless learning technique; 7-day retention was better with errorless learning in young children with mild TBI. Seventy-seven-day retention revealed an advantage for errorless learning in younger children with severe TBI., Conclusions: Findings did not support errorless learning as a generalized intervention for learning difficulties after TBI or identify specific age- or injury-severity groups that benefited from this technique.

Objective: To examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI)., Design: Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design., Setting: Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital., Participants: Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29)., Interventions: Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community., Main Outcome Measures: Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire., Results: All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge., Conclusions: The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.

While there has been strong evidence for the ability of neuropsychological performance at resolution of posttraumatic amnesia to predict later productivity, there has been less conclusive evidence for the relationship of neuropsychological test scores to concurrent productivity status. The purpose of the current study was to evaluate the relationship of neuropsychological test performance at 1 year post-injury to productivity assessed at the same time point. Participants were 518 persons with medically documented TBI who were enrolled in the TBI Model Systems Research and Demonstration Project. Stepwise logistic regression was utilized to determine the contributions of neuropsychological test scores to productivity after accounting for demographic characteristics, injury severity, and pre-injury productivity. Missing neuropsychological test scores were accounted for in the model. Variables that remained in the model and accounted for a significant proportion of the variance included age, duration of impaired consciousness, pre-injury productivity, and scores on measures of GOAT, Logical Memory II, and Trail Making Test, part B. The results indicate that neuropsychological test performance provides important information regarding the ability of persons with injury to return to productive activities. The results also indicate that inability to complete neuropsychological tests at 1 year post-injury is associated with non-productive activity.

Objectives: To examine the occurrence of and characteristics associated with violent traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems (TBIMS) project for 4 of the 5 original Model Systems centers and to determine the patient characteristics of this group, as well as the risk factors for sustaining such an injury., Design: Prospective evaluation of individuals with violent TBI over a 10-year period., Setting: Four TBIMS centers., Participants: A total of 1,229 individuals who received acute hospitalization and inpatient rehabilitation care for TBI., Interventions: Not applicable., Main Outcome Measure: The occurrence of a violent TBI., Results: Twenty-six percent of the participants in the TBIMS project sustained a violent TBI. This type of injury was more common in African-American men who were single and slightly older than the average TBI patient, were unemployed before injury, and had had a previous TBI. A higher injury rate was noted in the earlier part of the evaluation period. Those who sustained a violent TBI had higher levels of caregiver burden and disability, as well as decreased productivity and community reintegration at rehabilitation discharge and at 1 and 2 years postinjury., Conclusions: The occurrence of violent TBI in the TBIMS project is consistent with national trends of decreasing incidence of violent injuries in the 1990s. These results present a profile of those who have been injured through violence. The relative risks for sustaining such an injury appear to be well defined when considering demographic and temporal factors.

Objective: To characterize the preinjury family functioning, emotional distress, and social support of caregivers of persons with traumatic brain injury (TBI)., Design: Inception cohort., Setting: Three Traumatic Brain Injury Model Systems centers' inpatient rehabilitation facilities., Participants: One hundred ninety-one caregivers, primarily white and female, of persons with TBI., Interventions: Not applicable., Main Outcome Measures: The Brief Symptom Inventory, Family Assessment Device, Multidimensional Scale of Perceived Social Support, and history of medical and psychiatric illness., Results: Thirty-seven percent of caregivers indicated symptoms of emotional distress consistent with psychiatric diagnoses for the month before injury, whereas 27% reported a history of psychiatric or psychologic treatment at some point in the past. Between 25% and 33% of caregivers reported unhealthy family functioning in 1 or more areas for the month before injury. Persons with an annual income less than US dollars 10,000 reported less healthy preinjury family functioning. Caregivers reported good satisfaction with preinjury social support, and very few caregivers reported a history of substance abuse., Conclusion: A substantial proportion of caregivers reported emotional distress and/or unhealthy family functioning before injury. Such difficulties may make them more vulnerable to the stress associated with injury and result in greater coping difficulties.

Objective: Evaluate changes in community integration for survivors of traumatic brain injury (TBI) who participated in a post-acute rehabilitation programme., Design: Cohort, prospective study investigating change from admission to post-discharge., Participants: Individuals, the majority of whom were diagnosed with severe TBI, were placed into one of two groups as follows: (1). admitted for treatment less than 1 year post-injury (L1Y) or (2). admitted for treatment between 1-5 years post-injury (G1Y)., Measure: The Community Integration Questionnaire (CIQ)., Results: Both groups showed significant improvements from admission to follow-up; however, some CIQ findings were more pronounced for the L1Y group. Reliable change (RC) methodology was used to assess individual change. Results of this approach were consistent with group results, but tempered the perception of degree of change., Conclusions: Findings cannot simply be attributed to neurological recovery and individual factors are important to examine when assessing change.

Primary Objective: To investigate the relationship of family functioning to patients' progress in a post-acute TBI rehabilitation programme., Research Design: Cohort study investigating predictors of change from admission to follow-up., Methods and Procedures: Caregivers of 37 persons with severe TBI consecutively admitted to a residential post-acute rehabilitation facility completed the Family Assessment Device (FAD) within a few weeks of admission. The Disability Rating Scale (DRS) was completed upon admission and approximately 1 month after discharge. FAD scores were used to predict DRS change scores after controlling for injury severity, admit FAD scores, and time from admission to follow-up., Main Outcomes and Results: Persons with unhealthy family functioning showed less improvement on DRS total, level of functioning (LOF), and employability (EMP) scores., Conclusions: The results emphasize that family functioning is an important variable to include in future models predicting rehabilitation outcome, and the importance of family intervention as part of the rehabilitation process.

Objective: To evaluate the contribution of early cognitive assessment to the prediction of productivity outcome after traumatic brain injury (TBI) adjusted for severity of injury, demographic factors, and preinjury employment status., Design: Inception cohort., Setting: Six inpatient brain injury rehabilitation programs., Participants: A total of 388 adults with TBI whose posttraumatic amnesia (PTA) resolved before discharge from inpatient rehabilitation., Interventions: Administered neuropsychologic tests during inpatient stay on emergence from PTA. Follow-up interview and evaluation. Predictor measures also determined., Main Outcome Measure: Productivity status at follow-up 12 months postinjury., Results: Multiple logistic regression analysis revealed that preinjury productivity status, duration of PTA, education level, and early cognitive status each made significant, independent contributions to the prediction of productivity status at follow-up. When adjusted for all other predictors, persons scoring at the 75th percentile on early cognitive status (less impaired) had 1.61 times greater odds (95% confidence interval [CI], 1.07-2.41) of being productive follow-up than those scoring at the 25th percentile (more impaired). Without adjustment, persons scoring at the 75th percentile had 2.46 times greater odds (95% CI, 1.77-3.43) of being productive at follow-up., Conclusions: Findings support the utility of early cognitive assessment by using neuropsychologic tests. In addition to other benefits, early cognitive assessment makes an independent contribution to prediction of late outcome. Findings support the clinical practice of performing initial neuropsychologic evaluations after resolution of PTA., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To investigate maintenance of gains after discharge from a postacute rehabilitation program., Design: Longitudinal cohort study, with inclusion based on availability of subjects at three time points., Setting: Comprehensive postacute rehabilitation program in the Southern United States., Participants: Thirty-four persons with medically documented complicated mild to severe traumatic brain injury; primarily male Caucasians with some college., Main Outcome Measures: Disability Rating Scale and the Community Integration Questionnaire completed at admission, discharge, and two follow-up time points., Results: Repeated measures analyses, using time from injury to discharge as a covariate, revealed significant improvements on all measures from admission to discharge, with no significant change from discharge to either of the follow-up periods. However, substantial changes were noted in individual cases., Conclusions: The results indicate that gains made by persons with traumatic brain injury during postacute rehabilitation are generally maintained at long-term follow-up, but changes occur in individual cases. Long-term services may help prevent decline in individual cases.

Objective: To investigate the incidence and cause of rehospitalizations 1 and 5 years after traumatic brain injury., Design: Descriptive statistics were computed in a prospective study of the cause and incidence of rehospitalizations at years 1 and 5 after injury. Analysis of variance and chi-square tests were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics., Setting: Seventeen medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services., Participants: Eight hundred ninety-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1999 were examined at 1-year follow-up., Main Outcome Measures: Incidence and cause of rehospitalization at 1 and 5 years after injury., Results: The incidence of rehospitalization ranged from 22.9% 1 year after injury to 17.0% at 5 years after injury. At 1 year after injury, a third of the rehospitalizations were for elective reasons. At 5 years after injury, the incidence of readmissions for seizures and psychiatric difficulties and general health maintenance increased substantially. T-tests and chi-square analyses were performed on the 5-year follow-up data to compare those rehospitalized for unplanned reasons with those not rehospitalized., Conclusions: There remains a relatively high rate of rehospitalization in the long term after traumatic brain injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Objective: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury., Design: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury., Setting: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care., Participants: One hundred eighty-two persons with complicated mild to severe traumatic brain injury., Primary Outcome Measures: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard., Results: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures., Conclusions: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Objective: To evaluate whether early neuropsychologic testing is useful in predicting long-term productivity outcome after traumatic brain injury (TBI)., Design: Validation cohort prediction study., Setting: Four inpatient brain injury rehabilitation programs participating in the Traumatic Brain Injury Model Systems project., Participants: A total of 293 adults with nonpenetrating TBI., Main Outcome Measures: Fifteen neuropsychologic tests were administered to patients who emerged from posttraumatic amnesia before rehabilitation discharge. Test scores were classified in the normal range or impaired range, using objective criteria. Outcome was defined as productive if the patient was competitively employed or enrolled full time in regular education., Results: Productivity at follow-up was predicted by completion of at least 1 neuropsychologic test before discharge, by an injury-test interval of less than 2 months, and by normal range scores on 10 of the 15 neuropsychologic tests. Normal range scores on these tests increased the probability of a productive outcome by 40% to 130%., Conclusions: Neuropsychologic testing can help predict long-term productivity even when performed before discharge from inpatient rehabilitation and at variable injury-test intervals. Early testing should be interpreted in relation to injury-test interval. Because tests of multiple neuropsychologic domains predicted outcome, comprehensive evaluations might be more useful in predicting outcome.

Assessment of current level of functioning among clients with traumatic brain injury (TBI) often guides the establishment of realistic outcome goals for post-acute rehabilitation. Further, data generated from neuropsychological testing provide a clinician with a better understanding of a client's pattern of cognitive strengths and weaknesses. The Disability Rating Scale (DRS) is commonly used by TBI rehabilitation facilities to assess a client's general level of functioning in terms of impairment, disability, and handicap. Previous studies have used clients' neuropsychological test results to predict future level of functioning. These studies have shown mixed results regarding the predictive validity of the test findings; however, they usually employ only a limited number of tests for prediction representing a limited number of cognitive domains. Using a concurrent validity design, the present study investigated the bivariate associations between various neuropsychological testing domains (i.e. intellectual, academic, language, visuoperceptual, memory, and executive functioning) and level of functioning as indexed by the DRS. Participants were administered the DRS and the neuropsychological evaluation during the initial part of post-acute rehabilitation. Composite scores were derived for each of the neuropsychological domains. Most participants were categorized as sustaining a severe TBI. The mean age and education of this predominately male sample was 28.84 years (SD = 9.13) and 11.83 years (SD = 1.7), respectively. Results revealed a significant positive relationship between performances in intellectual, executive, academic, and visuoperceptual domains and level of functioning.

Within the context of a post-acute rehabilitation setting, association and agreement between results from the Neurobehavioural Cognitive Status Examination (NCSE) and from the neuropsychological (NP) evaluation are examined. All participants (n = 48) had sustained a severe traumatic brain injury and NCSE testing preceded NP testing by an average of 1 month. A significant relationship and fair classification agreement (i.e. presence or absence of cognitive impairment) was found between the overall results from NCSE and NP evaluation. Significant relationships were also observed between most NCSE subtests and paired NP tests thought to be assessing the same cognitive domains. However, the classification agreement (i.e. the presence or absence of deficient performance) between most NCSE subtests and paired NP tests was poor. The findings are discussed from the standpoint of individual treatment planning.

Objective: To investigate the factor structure and concurrent validity of the Community Integration Questionnaire (CIQ), using a large sample of persons with traumatic brain injury (TBI)., Design: Principal components analysis with varimax rotation was performed on CIQ items completed through interview with patients at 1 year after injury. Correlational analyses compared CIQ scores to scores on other widely used outcome measures., Setting: Outpatient clinics affiliated with four TBI Model System rehabilitation centers funded by the National Institute on Disability and Rehabilitation Research., Participants: Three hundred twelve patients with medically documented TBI who were enrolled in the TBI Model Systems Project. The majority of patients were Caucasian males with severe TBI., Main Outcome Measures: CIQ; Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Disability Rating Scale (DRS)., Results: Three factors emerged: Home Competency, Social Integration, and Productive Activity. The financial management item was moved from Social Integration to Home Competency, and the travel item was moved from Productive Activity to Social Integration. Each CIQ scale score showed significant correlations in the expected direction with the FIM+FAM and DRS items., Conclusions: The results provide further evidence for the validity of the CIQ and improve the scoring system. The factor structure is clinically and theoretically meaningful. The subscale and total scores show significant relationships with other widely used measures of outcome. Future research should focus on increasing the range of questions, accounting for changes from preinjury functioning, and obtaining normative data on the new factors.

Objective: To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury., Design: Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics., Setting: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services., Participants: Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996., Main Outcome Measures: Annual incidence and etiology of rehospitalization., Results: The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05)., Conclusions: There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Impaired awareness of the effects of brain injury is a commonly observed and poorly understood finding in traumatic brain injury survivors. Nonetheless, impaired awareness has been identified as a major factor in determining outcome for traumatic brain injury survivors. Review of previous studies of impaired awareness in this patient population revealed a number of preliminary findings regarding the nature of this phenomenon. The present paper presents the results of 2 new studies with a total of 111 traumatic brain injury patients conducted to bring further clarity to this area. Findings confirmed and extended many results of previous investigations. Specific findings included patient overestimation of functioning as compared to family member ratings, patient report of greater physical than nonphysical impairment, greater patient-family agreement on specific ratings of patient functioning than on general ratings, greater agreement of family and clinician ratings of patient functioning with each other than with patient self-ratings, and partial disagreement of different methods of measuring impaired awareness.

Impaired self-awareness of deficits is a common finding in patients who have suffered traumatic brain injury. Impaired awareness can limit motivation for treatment and contribute to poor outcome. Consequently, it is important for brain injury rehabilitation professionals to understand this phenomenon and utilize treatment approaches that may improve patient awareness. The present article reviews the existing literature on measurement of impaired awareness, characteristics of impaired awareness, the relationship of impaired awareness to functional outcome, possible treatment approaches for impaired awareness and empirical investigations of interventions to improve awareness. The treatment strategies we use to address impaired awareness in our community re-integration program for brain injury survivors are described in detail. These approaches include: establishment of the therapeutic alliance, family interventions, peer feedback, education, roleplaying, videotape feedback, real world experiences, therapeutic milieu and psychotherapy.

The purpose of the current study was to investigate the contribution of coping strategies, subjective burden, and social support to psychological health in caregivers. The sample included 69 primary caregivers of patients with severe closed head injuries. There were three groups of caregivers: acute (0-6 months post-injury); intermediate (6 months-1.5 years); and long-term (> 1.5 years). All had participated in rehabilitation. Caregivers completed an interview and series of questionnaires, including the Ways of Coping Questionnaire, Social Support Questionnaire, Subjective Burden Measure, and General Health Questionnaire. The Disability Rating Scale was completed by staff to assess patients' level of functioning at the time of caregivers' assessment. ANOVA revealed no between-group differences in coping style or social support. Multiple regression revealed that greater use of emotion-focused coping was associated with greater emotional distress. Coping style contributed to a greater proportion of the variance in caregivers' psychological health that did patients' level of functioning. Increased satisfaction with social support was associated with less emotional distress. The full model, including group, caregiver gender, emotion-focused coping, social support, patient level of recovery, burden, and the burden x coping interaction accounted for over half of the variance in psychological health. Results support a multidimensional model for explaining caregivers' adjustment.

Objective: To extend psychometric research on the Community Integration Questionnaire (CIQ) by comparing patients' reports with those of family members., Design: Reports on community integration were obtained from family members and patients 1 year after brain injury. Kappa reliability coefficients were used to examine agreement for individual items on the questionnaire. Total scores for the three CIQ scales were compared between groups using independent samples t tests., Setting: Outpatient clinics affiliated with the four NIDRR traumatic brain injury Model System rehabilitation centers., Participants: CIQ data were obtained for 259 adult patients with traumatic brain injury. For 122 cases, patients and family members provided corresponding data. In 101 cases, only self-reported data were available. In 36 cases, information was provided solely by family members. All patients received inpatient rehabilitation and were at least 16 years of age. The full range of brain injury severity was represented., Main Outcome Measure: The 15-item CIQ, comprised of three scales, Home Integration, Productive Activity, and Social Integration., Results: Analysis of kappa values found "moderate" to "almost perfect" agreement levels for all 15 items. Almost-perfect ratings were found for three of the four items on the Productive Activity Scale. Comparisons were made between scale scores derived from patients and families. The Home Integration scale showed differences, with patient scores higher than those reported by family members (t = 3.51, p < .01). However, the difference in scores was attributable to small discrepancies on two items and was not considered clinically meaningful. The Total CIQ score also showed a difference, with patients reporting significantly higher levels of integration relative to family members (t = 2.30, p < .05). This difference was also attributable to discrepancies on two items of the Home Integration Scale., Conclusions: The results have important implications for researchers who may be limited to one source of data. The hypothesis that patients and family members have very different perspectives of patients' community activities was not supported. Rather, similar ratings of individual activities were given with two exceptions, meal preparation and housekeeping. More research is needed to delineate relationships between agreement ratings and outcome categories.

Fifty patients who sustained mild to moderate closed head injury (CHI) underwent a CT scan, MRI, and neurobehavioural testing. At baseline 40 patients had intracranial hyperintensities detected by MRI which predominated in the frontal and temporal regions, whereas 10 patients had lesions detected by CT. Neurobehavioural data obtained during the first admission to hospital disclosed no distinctive pattern in subgroups of patients characterised by lesions confined to the frontal, temporal, or frontotemporal regions, whereas all three groups exhibited pervasive deficits in relation to normal control subjects. The size of extraparenchymal lesion was significantly related to the initial Glasgow Coma Scale score, whereas this relation was not present in parenchymal lesions. One and three month follow up MRI findings showed substantial resolution of lesion while neuropsychological data reflected impressive recovery. The follow up data disclosed a trend from pervasive deficits to more specific impairments which were inconsistently related to the site of brain lesion. These results corroborate and extend previous findings, indicating that intracranial lesions detected by MRI are present in most patients hospitalised after mild to moderate CHI. Individual differences in the relation between site of lesion and the pattern of neuropsychological findings, which persist over one to three months after mild to moderate CHI, remain unexplained.

The outcome 1 year after they had sustained a severe head injury was investigated in patients who were admitted to the neurosurgery service at one of four centers participating in the Traumatic Coma Data Bank (TCDB). Of 300 eligible survivors, the quality of recovery 1 year after injury was assessed by at least the Glasgow Outcome Scale (GOS) in 263 patients (87%), whereas complete neuropsychological assessment was performed in 127 (42%) of the eligible survivors. The capacity of the patients to undergo neuropsychological testing 1 year after injury was a criterion of recovery as reflected by a significant relationship to neurological indices of acute injury and the GOS score at the time of hospital discharge. The neurobehavioral data at 1 year after injury were generally comparable across the four samples of patients and characterized by impairment of memory and slowed information processing. In contrast, language and visuospatial ability recovered to within the normal range. The lowest postresuscitation Glasgow Coma Scale (GCS) score and pupillary reactivity were predictive of the 1-year GOS score and neuropsychological performance. The lowest GCS score was especially predictive of neuropsychological performance 1 year postinjury in patients who had at least one nonreactive pupil following resuscitation. Notwithstanding limitations related to the scope of the TCDB and attrition in follow-up material, the results indicate a characteristic pattern of neurobehavioral recovery from severe head injury and encourage the use of neurobehavioral outcome measurements in clinical trials to evaluate interventions for head-injured patients.

The pattern of recovery of orientation to person, place, and time was investigated in 84 patients who were initially disoriented while hospitalized on the neurosurgery service after sustaining a closed-head injury (CHI) of varying severity. Results of daily administration of the Galveston Orientation and Amnesia Test revealed that the most common sequence of recovery of orientation was person, place, and time: accounting for about 70% of the patients. Return of orientation to time preceded reorientation to place in 13% of the patients while other orderings of reorientation were present in 11% of the cases. Temporal disorientation was initially characterized by backward displacement of the date from the actual date in 68% of the patients. The magnitude of this displacement progressively shrank as the patients became more oriented. Patients who exhibited the greatest backward displacement of the date had more severe and persistent impaired consciousness, were older and had longer durations of posttraumatic amnesia. These data support Ribot's hypothesis that older memories are relatively resistant to cerebral insult.

Twenty patients admitted for minor or moderate closed-head injury were studied to investigate the relationship between magnetic resonance imaging (MRI) and neurobehavioral sequelae. The MRI scans demonstrated 44 more intracranial lesions than did concurrent computerized tomography (CT) scans in 17 patients (85%); most of these lesions were located in the frontal and temporal regions. Estimates of lesion volume based on MRI were frequently greater than with CT; however, MRI disclosed no additional lesions that required surgical evacuation. Neuropsychological assessment during the initial hospitalization revealed deficits in frontal lobe functioning and memory that were related to the size and localization of the lesions as defined by MRI. Follow-up MRI and neuropsychological testing at 1 month (13 cases) and 3 months (six cases) disclosed marked reduction of lesion size paralleled by improvement in cognition and memory. These findings encourage further investigation of the prognostic utility of MRI for the clinical management and rehabilitation of mild or moderate head injury.

The presence of disproportionate memory impairment with relatively preserved intellectual functioning was examined in 87 survivors of moderate or severe closed head injury. Approximately one-fourth of the patients tested at 5 to 15 and/or 16 to 42 months after injury manifested defective memory on both auditory and pictorial measures despite obtaining Wechsler Verbal and Performance Intelligence Quotients within the average range. The findings indicate that disproportionately severe memory deficit persists in a subgroup of closed head injured survivors which is reminiscent in some cases of the amnesic disturbance arising from other causes. Evaluation of long term memory in relation to cognitive ability could potentially identify important distinctions for prognosis and rehabilitation in head injured patients.

Magnetic resonance imaging (MRI) was performed in a series of 21 children and adolescents who had been hospitalized after sustaining closed head injuries of varying severity at least 6 months previously. Areas of high intensity in the parenchyma were present in 8 of the 11 severely injured patients, whereas MRI findings were normal in all 10 patients with mild-to-moderate head injuries. Lesions involving the subcortical white matter were confined to severely injured patients whose clinical features were compatible with diffuse axonal injury. Neuropsychological assessment disclosed deficits primarily in the severely injured patients; these deficits were significantly associated with persistent lesions visualized by MRI. Serial MRI and neurobehavioral assessment following early injury may be useful in documenting cognitive impairment in relation to structural alterations of the young brain.

To investigate forgetting during recovery from head injury, colour slides were initially projected for long durations to ensure acquisition on a recognition test given 10 minutes later. Patients tested during posttraumatic amnesia (PTA) exhibited accelerated forgetting over 32 hours as compared with head trauma patients studied after the period of PTA and normal controls.

To investigate the automatic versus effortful distinction following severe closed head injury (CHI), we administered free recall and frequency of occurrence tasks to patients and controls. In Experiment 1 we found that both free recall (an effortful task) and judgment of relative frequency of occurrence (an automatic task) were impaired in 15 CHI patients as compared to 14 controls. In Experiment 2 we corroborated this finding and showed that absolute estimates of frequency were also impaired in new samples of 16 patients and 16 controls. We infer that cognitive tasks which normal individuals can perform without practice, feedback, or instructions may demand more effortful strategies following severe CHI.

In a prospective investigation of neurobehavioral functioning in young boxers, 13 pugilists and 13 matched control subjects underwent tests of attention, information-processing rate, memory, and visuomotor coordination and speed. The results disclosed more proficient verbal learning in the control subjects, whereas delayed recall and other measurements of memory did not differ between the two groups. Reaction time was faster in the boxers than in the control subjects, but no other differences were significant. Ten subjects in each group were retested 6 months later and exhibited improvement in their neuropsychological performance as compared to baseline measurements. However, there were no differences in scores between the boxers and the control subjects at the follow-up examination or in the magnitude of improvement from baseline values. Magnetic resonance imaging, which was performed in nine of the boxers, disclosed normal findings.

Magnetic resonance (MR) imaging was performed in 94 patients who sustained closed head injury of varying severity. Results of MR studies obtained after the intensive care phase of treatment disclosed that intracranial lesions were present in about 88% of the patients. Consistent with the centripetal model of progressive brain injury proposed in 1974 by Ommaya and Gennarelli, the depth of brain lesion was positively related to the degree and duration of impaired consciousness. Further analysis indicated that the relationship between depth of brain lesion and impaired consciousness could not be attributed to secondary effects of raised intracranial pressure or to the size of intracranial lesion(s).

The P-300 component of evoked potentials to a rare tone was measured in normal volunteers and in patients with closed head injuries who either were confused (in posttraumatic amnesia) or had recovered from posttraumatic amnesia and were oriented at the time of recording. The latency of this component, which reflects cortical processing of stimuli, varied reliably, with the degree of orientation being longest for confused patients and shortest for normal subjects. On the basis of these data, we suggest that the P-300 latency can be used as a physiological index of cognitive function in patients with closed head injury.

In order to investigate post-traumatic hemispheric disconnection effects, dichotic listening and intermanual tasks were administered to 69 patients who had sustained a closed head injury of varying severity. The manual tasks consisted of naming objects palpated in either hand, transfer of postures from one hand to the other and writing. Consistent with predictions, the degree of ear asymmetry in dichotic listening performance was directly related to the severity of the head injury as reflected by the degree of impaired consciousness. Depth and localisation of parenchymal lesion characterised by magnetic resonance imaging were also related to the degree of ear asymmetry. Parenchymal lesions situated in sites which could potentially interfere with callosal auditory or geniculocortical pathways produced a greater disparity in response to left versus right ear inputs as compared with parenchymal lesions in areas such as the frontal lobes which are purportedly unrelated to asymmetries in dichotic listening performance. The results provide further evidence for the effects of multifocal brain lesions involving the white matter on tasks which require intra and/or interhemispheric integration.