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Objective: Our primary outcome was to determine the feasibility of patients with post‐traumatic headache (PTH) keeping a daily headache diary and using sumatriptan as directed. Secondary outcomes include determining if sumatriptan is effective in aborting PTH and whether headache resolution is dependent on PTH phenotype. Background: PTH is prevalent and persistent after traumatic brain injury, yet there have been few studies evaluating the effects of pharmacological treatments in individuals with PTH. Methods: This is a single‐arm, prospective, non‐randomized phase 2 clinical trial registered at Clinicaltrials.gov (NCT01854385) and conducted from 2013 to 2017. Data analysis was completed in 2022. Of the 299 participants screened, 40 were enrolled in the study. Participants kept a headache diary documenting headache characteristics and severity. Headache characteristics were used to determine PTH phenotypes of migraine‐like, probable migraine‐like, or non‐migraine‐like. Participants reported whether sumatriptan was used for their headache, their response to the medication, if a second dose was taken, and their response to the second dose. Results: A total of 15 participants out of the 40 enrolled (mean [SD] age, 41.9 [14.2] years, and 53% [21/40] male), met the criteria for the use of sumatriptan, and completed all assessments. Average headache diary compliance rate for the final month of the study was 80% (372/465). While sumatriptan was used for only 19% (122/654) of all reported headaches, 72% (88/122) of those headaches resolved within 2 h of taking the medication. Resolution of headaches with sumatriptan was not significantly different among headache phenotypes (migraine‐like: 22/38 [58%], probable migraine‐like: 24/29 [83%], non‐migraine‐like: 6/15 [40%]; p = 0.154). Conclusions: A daily headache diary is feasible for tracking headache symptoms. Preliminary results also suggest that sumatriptan, a migraine‐specific medication, may be beneficial for the treatment of PTH of different clinical phenotypes. Future studies, such as a phase 3 clinical trial with a larger sample size, are needed to better understand the efficacy of sumatriptan in the treatment of PTH. Plain Language Summary: Headache is the most common persistent symptom after traumatic brain injury, yet there are no evidence‐based treatments for post‐traumatic headache (PTH). In this study, we evaluated the ability of individuals with PTH to complete a daily headache diary and their response to treatment with sumatriptan. About 80% of participants completed the daily headache diary, and 72% of headaches resolved within 2 h of taking sumatriptan, so we concluded that a daily headache diary is useful in documenting headache symptoms and sumatriptan may be an effective treatment for PTH. [ABSTRACT FROM AUTHOR]

Introduction: Chronic pain is common after traumatic brain injury (TBI), frequently limits daily activities, and is associated with negative outcomes such as decreased community participation. Despite the negative impact of chronic pain, few people with TBI receive effective treatment. This paper describes a collaborative care (CC) intervention, TBI Care, adapted specifically to treat chronic pain in people living with TBI, emphasizing expert clinician input, cognitive behavioral therapy (CBT) techniques, and other nonpharmacological approaches for decreasing pain interference. Methods: 79participantsengagedintheCCintervention fromtwoacademicmedical rehabilitation clinics with weekly assessments of pain intensity, interference, and medication use. Participant feedback on the intervention was gathered by interview with the care manager (CM) at the last treatment session and/or booster session. Provider feedback was gathered by a confidential survey post intervention. Results: Ninety percent of participants received at least 11 of the target 12 sessions with a care manager (CM), the majority occurring over the phone. Participants endorsed an average of 7 pain locations. All participants received pain education, skills in self-monitoring, goal setting/behavioral activation and relaxation training. Pain interference scores (impact on activity and enjoyment), tracked weekly by the CM, significantly decreased across sessions. 89% of participants received recommendations for CBT skills, 65% received referrals for additional treatments targeting pain interference, and 43% received care coordination. 75% of participants reported 6 or more medications/supplements at both the first and last session, with changes recommended primarily for headache treatment. Feedback from participants and providers was positive. Discussion: TBI Care, a novel patient-centered CC approach, was flexibly delivered, tailored to the needs of those living with TBI and chronic pain, with a high level of participant engagement, and satisfaction among participants and providers. This approach, prioritizing pain self-management strategies and other non-pharmacological approaches, along with optimizing pharmacological treatment, led to significant reductions in self-reported pain interference and intensity during the intervention. Using a CC model in TBI is feasible and successfully improved access to evidence-based treatments for chronic pain as well as outcomes for pain interference and intensity. [ABSTRACT FROM AUTHOR]

Background: Violence is the third leading cause of spinal cord injury (SCI) in the United States, and people with violence‐related SCI have worse long‐term outcomes compared to other traumatic SCI etiologies. Little is known, however, about the underlying reasons for these differences. Access to and utilization of rehabilitation services may differ in this population, but their outpatient care has not been previously investigated. Objective: To evaluate differences in utilization patterns of outpatient rehabilitation services between people with violence‐related SCI and other traumatic SCI etiologies. Design: Retrospective cohort study. Setting: Academic tertiary care hospital system. Patients: A total of 41 patients with violence‐related SCI residing in King County at the time of injury who completed inpatient rehabilitation (IPR) in our institution were identified from the hospital trauma registry and matched with 41 control patients with nonviolent traumatic SCI. Interventions: Not applicable. Main Outcome Measure(s): The number of appointments attended, canceled, and missed during the first year after discharge from IPR were obtained by chart review for physical medicine & rehabilitation (PM&R) physicians and therapy services. Results: People with violence‐related SCI had decreased follow‐up with outpatient rehabilitation services after IPR discharge compared to non‐violent traumatic SCI, including PM&R (2.50 ± 2.44 vs. 3.76 ± 2.21 visits, β = −1.28, p =.017), physical therapy (8.91 ± 11.02 vs. 17.57 ± 15.26, β = −9.79, p =.009), occupational therapy (4.28 ± 7.90 vs. 10.04 ± 14.42, β = −6.18, p =.033), and recreational therapy (0.293 ± 0.955 vs. 1.37 ± 2.86, β = −1.07, p =.035). The rate of missed appointments was also higher among people with violence‐related SCI compared to controls for PM&R (25.2% ± 28.5% vs. 9.9% ± 16.5%, β = 14.6%, p =.014) and physical therapy (26.0% ± 32.0% vs 4.2% ± 13.2%, β = 22.1%, p =.009). Conclusions: Individuals with violence‐related SCI had fewer follow‐up appointments with PM&R physicians and other allied health professionals and were more likely to miss scheduled appointments compared to other traumatic SCI etiologies. Decreased outpatient follow‐up may affect long‐term outcomes for people with violence‐related SCI. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 Measure(s): 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. [ABSTRACT FROM AUTHOR]

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 Measure(s): 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfaction with medical care. Method: A total of 12,769 Medicare Current Beneficiary Survey respondents age 65 and older in 2001 were categorized by level of communication disability. Sampling weights were used to make inferences about the entire Medicare population. Results: Over 16 million beneficiaries reported a communication disability. Hearing problems were most commonly reported (41.99%). The association between dissatisfaction and communication disability was statistically significant (p [less than or equal to 0.05) for 8 of 10 items. Conclusions: Prevalence of dissatisfaction among those with a communication disability varied, ranging from 3.43% to 19.34%. Respondents with a communication disability reported much more dissatisfaction when compared with those respondents without a communication disability.

Objective: To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme. Setting: TBI Model Systems centers. Participants: Individuals 16 years and older with a primary diagnosis of TBI. Design: Prospective cohort study. Main Measures: Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. Results: The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities. Conclusion: Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization. [ABSTRACT FROM AUTHOR]

• Those with more severe traumatic brain injury described more barriers to accessing care. • Ease of communication with providers was the most common facilitator. • Distance from facilities was the most common barrier. • Tailored approaches for those with greater disability are needed to improve access. To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups. Qualitative descriptive study guided by an access to health care services conceptual framework. Five Veterans Affairs (VA) polytrauma rehabilitation centers. SMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe). Barriers and facilitators accessing care. The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services. Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability. [ABSTRACT FROM AUTHOR]