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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.

To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI).Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices.Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour).Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes.Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901.Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study.

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.TBI Model Systems centers.Individuals 16 years and older with a primary diagnosis of TBI.Prospective cohort study.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.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.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.

OBJECTIVE: To examine the utility of the sleep disturbance item of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for insomnia among individuals with moderate to severe traumatic brain injury (TBI). SETTING: Telephone interview. PARTICIPANTS: A sample of 248 individuals with a history of moderate to severe TBI participated in an interview within two years of their injury. DESIGN: Observational, cross sectional analysis. MAIN MEASURES: The PHQ-9 was administered along with the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Sleep Hygiene Index, Epworth Sleepiness Scale, and the Insomnia Interview Schedule. RESULTS: Receiver operating characteristic curve analysis was conducted for the PHQ-9 sleep item rating against a set of insomnia criteria to determine an optimal cut-off score. A cut-off of 2 on the PHQ-9 sleep item maximized sensitivity (76%) and specificity (79%) with an area under the curve of 0.79 (95% CI=0.70 to 0.88). The two groups formed using this cut-off differed significantly on all sleep measures except the Epworth Sleepiness Scale. CONCLUSIONS: The PHQ-9 sleep item may serve as a useful screener to allow for detection of potential sleep disturbance among individuals with moderate to severe TBI. Those who screen positive using this item included in a commonly used measure of depression can be prioritized for further and more comprehensive assessment of sleep disorders.

Objective The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. Methods The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. Results Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed “a lot” or “some” interest in learning more, but only 19% reported “a lot” of knowledge. Respondents reported “a lot” of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). “None” or “some” knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). Conclusion Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. Impact Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Introduction Sleep disturbance and chronic pain are very common after moderate to severe traumatic brain injury (msTBI). Despite having a bidirectional and mutually exacerbating relationship, there is a dearth of literature examining factors involved in the sleep-pain relationship following msTBI. Psychiatric symptoms (e.g., post-traumatic stress, depression) are also prevalent following injury and know to be related to sleep, as well as poor adjustment to chronic pain. The purpose of this study was to examine associations between sleep, psychiatric symptoms, and pain-beliefs among msTBI survivors who have comorbid chronic pain. Methods This is a secondary analysis of TBI Model Systems study data of 1,567 individuals reporting chronic pain after msTBI (M=8.5 years, SD=7.1). Participants were 46.8 years old on average (SD=27.9), predominantly male (72.7%) and completed measures of sleep (Pittsburgh Sleep Quality Index; PSQI), post-traumatic stress disorder (PTSD Checklist; PCL-5), depression (Patient Health Questionnaire; PHQ-9), anxiety (General Anxiety Disorder; GAD-7), pain-related catastrophizing (Coping Strategies Questionnaire; CSQ) and self-efficacy (Pain Self-Efficacy Questionnaire; PSEQ-2). Measures were adjusted for overlapping constructs. Relationships between sleep, psychiatric symptoms and pain beliefs were examined through Pearson correlations. Results Average PSQI total score for our sample was 8.78 (SD=4.4), indicating poor sleep quality, with an estimated 6.40 (SD=1.9) hours of sleep on average. Over two-third (68.5%) of our sample attributed some of their sleep disturbance to chronic pain and nearly half (47.4%) met cutoff (>8) for clinically significant poor sleep quality. PSQI scores were positively correlated with PCL (r = .44, p Conclusion Poorer sleep quality in individuals with chronic pain after msTBI is associated with more psychiatric symptoms, increased pain-related catastrophizing, and lower pain self-efficacy. Results highlight sleep quality as an important modifiable target for intervention in this at-risk clinical population and suggest that behavioral treatments to improve psychiatric comorbidities and adjustment to pain may be beneficial. Support (if any) National Institute on Disability, Independent Living, and Rehabilitation Research (NCT03033901).

Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often co-occurs with psychological and medical conditions such as posttraumatic stress disorder (PTSD) and sleep apnea. We aimed to examine if sleep apnea is associated with the presence and severity of PTSD in V/SM with TBI of all severities.The study examined participants at varying times since their TBI (Almost 32% of the sample stated they had been diagnosed with sleep apnea. In those reporting sleep apnea, 32% also had probable PTSD; 19% of those without sleep apnea had probable PTSD. The regression demonstrated sleep apnea was significantly associated with PTSD symptom severity (TBI, PTSD, and sleep apnea are often comorbid in V/SM. We expand the literature by demonstrating that sleep apnea was associated with PTSD severity. A multipronged approach to TBI rehabilitation that addresses sleep and psychological distress is recommended for enhancing health outcomes in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Introduction Poor sleep quality and chronic pain are common after moderate-to-severe traumatic brain injury (msTBI). Prior studies have not examined the role of PTSD symptoms in the relationship between sleep quality and chronic pain experience (i.e., severity and pain-related interference) in those with msTBI. Yet, PTSD is known to be associated with both sleep and pain. The purpose of this analysis is to determine the role of PTSD symptoms in the sleep-pain relationship among this at-risk clinical population. Methods Secondary analyses were performed on data (n=1537) from the TBI Model Systems follow-up study. Participants were an average age of 46.21 years old, predominantly male (72.61%), and followed at an average of 8.5 years post injury. Participants completed measures of sleep quality (Pittsburgh Sleep Quality Index; PSQI), pain severity and interference (Brief Pain Inventory; BPI), depression (Patient Health Questionnaire-9; PHQ-9) and PTSD symptoms (PTSD Checklist, PCL-5). Analysis of covariance (ANCOVA) was used to examine differences in pain outcomes controlling for relevant covariates, adjusting for item redundancy prior to analyses. Results Sleep quality and pain interference are associated such that “good sleepers” (PSQI≤8, mean=4.92±2.17) have lower pain interference scores than “poor sleepers” (PSQI>8, mean=12.63±2.87), with a mean pain interference of 3.41±2.32 vs 5.26±2.45 (p< 0.0001). “Good sleepers” also had lower pain severity (4.22±1.78 vs 5.28±1.84, p< 0.0001), lower PTSD symptoms (14.62±13.46 vs 28.35±17.82, p< 0.0001), and less depression symptoms (5.32±4.97 vs 10.57±6.22, p< 0.0001) when compared to “poor sleepers.” Pain interference and severity were significantly related to all covariates at a Conclusion In patients with msTBI, sleep quality and pain interference are positively associated such that better sleep quality corresponds with lower pain interference, a relationship which remains when controlling for PTSD and multiple covariates. Addressing the sleep needs of patients with msTBI through behavioral intervention (e.g., cognitive behavioral therapy for insomnia), even in the presence of additional psychiatric comorbidities, may assist those who experience chronic pain following injury. Support (if any)

Objective: To examine the impact of bright white light (BWL) exposure on sleep quality in persons with recent traumatic brain injury (TBI).Design: Randomized, controlled device-sham studySetting: 3...

Objective To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor’s perspective. Design A cost-benefit analysis of phased approaches to sleep apnea diagnosis. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle–related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). Intervention Not applicable. Main Outcome Cost benefit. Results At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [–$5291], Multivariable Apnea Prediction Index MAPI [–$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (–$5210) and initial use of laboratory-quality polysomnography (–$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (–$6323) relative to the screening models (MAPI [–$6250], STOPBANG [–$6237) and initial assessment with polysomnography (–$5977) resulted in greater savings and cost-effectiveness. Conclusions The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

BACKGROUND: Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations. METHODS: We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated. RESULTS: Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79. CONCLUSION: The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries. LEVEL OF EVIDENCE: Epidemiologic/Therapeutic study, level IV.

OBJECTIVES The primary outcome of this study was to assess the efficacy and safety of preventive treatment with amitriptyline on headache frequency and severity after mild traumatic brain injury (mTBI). BACKGROUND Despite the fact that headache is the most common and persistent physical symptom after TBI, there has been little research on the longitudinal course or pharmacologic treatment of this disorder. Of those who have headache after injury, about 60% continue to complain of headache at 3 months post injury, with higher levels of disability than those without headache. There have been no prospective, randomized, controlled trials of a pharmacologic agent for headache after TBI. Additionally, a brain-injured population may be more susceptible to side effects of medication. DESIGN This is a single-center phase II trial of amitriptyline to prevent persistent headache after an mTBI. Medication dose was gradually increased from 10 to 50 mg daily. RESULTS Fifty participants were enrolled and 33 who completed the 90-day assessment were included in the final analysis. In order to detect a possible cognitive impact of the study drug, 24 participants were randomly assigned to start amitriptyline immediately after study enrollment and 26 were assigned to start 30 days after enrollment. Forty-nine percent (18/37) of those assigned to take medication took none throughout the study period, with less compliance in younger participants with mean ages of 32.7 in those who did not take any medication, 33.4 who were less than 80% compliant, and 42.3 who were compliant (P = .013). Compliance in keeping a daily headache diary was low, with 29/50 participants (58%) meeting daily entry completion, and only 10 participants maintaining 100% diary completion. No differences were found between those who started medication immediately vs at day 30 in headache frequency or severity. CONCLUSIONS While headache is the most common symptom following mTBI, current evidence does not support a specific treatment. No differences were noted in headache frequency compared to our prior study. However, the current sample had significantly lower headache severity (15% vs 36% with pain rating of 6 or above, P = .015) compared to our prior study. Our current study was not able to determine whether there is any benefit for the use of amitriptyline as a headache preventive because of difficulty with study recruitment and compliance. The challenges with recruitment and retention in the mTBI population were instructive, and future research in this area will need to identify strategies to improve recruitment, diary compliance, and medication adherence in this population.

Objective To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions. Design Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. Intervention Not applicable. Main Outcome Measures Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47). Results The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, −0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Objectives To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications. Setting Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI). Participants A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites. Design Cross-sectional, secondary analyses. Main measures The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index. Results After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids. Conclusion Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

OBJECTIVE To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). DATA SOURCES The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. RESULTS Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. CONCLUSIONS Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

Background Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. Objective The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. Research design Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. Results Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. Conclusion These lessons can help guide future pragmatic studies of care transitions.

Research Objectives To identify treatments utilized by Service Members and Veterans (SMVs) with TBI and chronic pain and characterize access barriers and facilitators to non-pharmacologic treatments. Design A secondary data analysis of SMV with TBI interview data guided by a biopsychosocial model of pain management1-3 and framework for accessing healthcare services4. Setting Five geographically diverse VA Polytrauma Rehabilitation Centers (PRC) within the Department of Veterans Affairs. Participants The secondary data analysis includes a sample of 55 SMVs with chronic TBI (>2 years) who were enrolled in VA TBI Model Systems. Half the sample had severe TBI (56%) with a mean age of 43 at time of injury, were male (93%), and married (51%). Interventions N/A. Main Outcome Measures Facilitators and barriers to accessing non-pharmacologic chronic pain treatment. Results Thematic analysis revealed that chronic pain and/or headache was a common rehabilitation need. The use of polypharmacy (including opioid use) was a common theme for those reporting chronic pain concerns. Facilitators to accessing treatment (including non-pharmacological treatments) for chronic pain included the ability to use the VA Choice Program to access community care and family or other social support to advocate for treatment. The primary barriers to accessing care for chronic pain included having insufficient information about alternative treatment options. Conclusions Despite VA/DoD clinical practice guidelines advising against using opioids in persons with documented TBI, polypharmacy emerged as a theme in this study cohort. Findings highlight facilitators and barriers to alternative evidence-based treatments with implications for practice and policy. Author(s) Disclosures None.

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p 0.001) and slower processing speed (r = 0.23, p 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p 0.001) and PTSD symptoms (r = 0.44, p 0.001), and slower processing speed (r = -0.22, p 0.001).The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Objective To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models. Design Cross-sectional, 1-5 days of data collection. Setting Community-based data collection. Participants Adults with chronic (>1 year), motor incomplete SCI (N=27). Interventions Not applicable. Main Outcome Measures Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results. Results The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models. Conclusions The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

We assessed safety and potential efficacy of a chamomile gel compared with urea cream to prevent acute radiation dermatitis in head and neck cancer patients. We assessed safety and potential efficacy of the chamomile gel in escalating concentrations of 2.50%, 5.00% and 8.35% of chamomile. Concentration of 8.35% was chosen for a randomized trial comparing chamomile gel (8.35%) with urea cream (n = 24 per group), for potential efficacy to delay or prevent radiation dermatitis in these patients. Preliminary results demonstrate a delayed onset of dermatitis, with onset of Grade 2 dermatitis at 5.1 (1.3) weeks in the chamomile group and 4.5 (1.3) weeks in the urea group (effect size of 0.46). Itching, burning and hyperpigmentation were more frequently reported in the urea group. Results indicates a potential efficacy of the chamomile gel. Further studies are needed to confirm the effect of the chamomile gel in reducing or delaying the occurrence of radiation dermatitis.

For patients surviving serious traumatic brain injury (TBI), families and other stakeholders often desire information on long-term functional prognosis, but accurate and easy-to-use clinical tools are lacking. We aimed to build utilitarian decision trees from commonly collected clinical variables to predict Glasgow Outcome Scale (GOS) functional levels at 1, 2, and 5 years after moderate-to-severe closed TBI. Flexible classification tree statistical modeling was used on prospectively collected data from the TBI-Model Systems (TBIMS) inception cohort study. Enrollments occurred at 17 designated, or previously designated, TBIMS inpatient rehabilitation facilities. Analysis included all participants with nonpenetrating TBI injured between January 1997 and January 2017. Sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5) after cross-sectional exclusions (death, vegetative state, insufficient post-injury time, and unavailable outcome). In our final models, post-traumatic amnesia (PTA) duration consistently dominated branching hierarchy and was the lone injury characteristic significantly contributing to GOS predictability. Lower-order variables that added predictability were age, pre-morbid education, productivity, and occupational category. Generally, patient outcomes improved with shorter PTA, younger age, greater pre-morbid productivity, and higher pre-morbid vocational or educational achievement. Across all prognostic groups, the best and worst good recovery rates were 65.7% and 10.9%, respectively, and the best and worst severe disability rates were 3.9% and 64.1%. Predictability in test data sets ranged from C-statistic of 0.691 (year-1; confidence interval [CI], 0.675, 0.711) to 0.731 (year-2; CI, 0.724, 0.738). In conclusion, we developed a clinically useful tool to provide prognostic information on long-term functional outcomes for adult survivors of moderate and severe closed TBI. Predictive accuracy for GOS level was demonstrated in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant.

To gather information about brain injury (BI) survivors' long-term healthcare needs, quality, barriers and facilitators.Qualitative content analysis of data gathered in focus groups using semi-structured interviews.Forty-four community-dwelling adults participated at two clinical research centres in Seattle, Washington and New York, New York. Participants were asked open-ended questions about their experiences with healthcare in the community with regard to care needs, utilization, access, barriers and facilitators to health management.Central themes emerged across three categories: 1) barriers to healthcare access/utilization, 2) facilitators to healthcare access/utilization, and 3) suggestions for improving healthcare after BI. The importance of communication as both a facilitator and barrier to care was mentioned by most participants. Compensatory strategies and external tools were identified as key facilitators of medical self-management. Finally, improving clinicians' knowledge about BI emerged as a potential solution to address health needs of individuals with chronic BI.Additional efforts need to be made to improve access to appropriate healthcare and increase the ability for individuals to successfully navigate the healthcare system. Findings suggest several specific, low-cost modifications to healthcare delivery and strategies for improving medical self-management that can maximize long-term health maintenance for BI survivors.

Introduction Obstructive Sleep Apnea (OSA) is prevalent after moderate to severe traumatic brain injury (TBI) and may diminish recovery when left untreated. Despite the demonstrated importance of treating OSA following TBI, assessment for OSA during or soon after inpatient rehabilitation for TBI is limited. Little is known about barriers to implementing OSA screening and early diagnosis during inpatient rehabilitation thus hindering the translation of evidence-based OSA assessment procedures into clinical practice and potentially delaying necessary OSA treatment. The current analysis explored facilitators and barriers to implementing OSA screening tools in an inpatient rehabilitation setting from the perspectives of end user stakeholders. Methods Patients, families, industry, clinical providers and administrators participated in a two-day meeting following completion of a diagnostic clinical trial of OSA screening and diagnostic tools during inpatient rehabilitation. Stakeholders were provided with open ended questions generated by study investigators and given the opportunity to respond on paper or a “graffiti wall” (i.e., white board). Example questions include “What are the greatest needs of the healthcare system related to sleep apnea and TBI?” and “What are the key things we need to consider to move results into real-world practice?” Qualitative content analyses using a rapid matrix approach were conducted from stakeholder feedback obtained during the two-day meeting, which included a guided review of emerging OSA research and discussion of potential implementation barriers of OSA assessment during inpatient rehabilitation. Results Improved screening and treatment practices for OSA were the greatest needs identified. To meet these needs, stakeholders identified the importance of improving patient, family, and staff understanding of OSA (e.g., health literacy) and other sleep disorders through education; inpatient rehabilitation access to resources (technology; sleep providers); and reimbursement for additional inpatient procedures. Conclusion Although treatment of OSA is crucial for recovery during inpatient rehabilitation following TBI, barriers to earlier recognition, diagnosis, and treatment of OSA exists across several different domains, including education, resources, and funding policies. Findings support future implementation efforts to translate evidence-based care into practice to improve patient outcomes. Support (if any) PCORI-NCT03033901

Research Objectives To identify differences sleep related respiration between those receiving and not receiving opioid medications. Design Cross-sectional, secondary analyses. Setting Acute inpatient rehabilitation for moderate to severe TBI. Participants 248 consecutive admissions who underwent level-1 polysomnography. Interventions Receipt of opioid medications on the day of polysomnography (PSG). Main Outcome Measures PSG including respiratory measures: oxygen saturation, central apneas events per hour, obstructive apneas and hypopnea events per hour, and total apnea-hypopnea index (AHI). Results After adjustment for number of prescribed medications, those receiving opioids on day of PSG experienced increased frequency of central sleep apnea events and higher frequency of obstructive sleep apnea events. Compared to those who did not, receiving opioids was associated with lower oxygen saturation nadir during and a greater number of oxygen desaturations across. Greater total AHI was observed for those receiving opioids. Conclusions Opioid use early after TBI appears to impact important sleep parameters and sleep related respiration that may influence recovery. Further investigation is needed to understand the impact of opioid medications, alone or in combination with other medications, on functional outcomes both early after TBI and in the chronic phase to develop recommendations on how and when to use these medications given their usage in managing pain after injury. Author(s) Disclosures Research reported in this article was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1511-33005). This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ13-C-0015; HT0014-19-C-0004) from the Defense Health Agency TBI Center of Excellence and National Institute on Disability, Independent Living, and Rehabilitation Research (University of Texas Southwestern Medical Center, 90DPTB0013-01-03; Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 90DRTB0002; Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine, 90DPTB0008). The TBI Model Systems is a funded collaboration between the Department of Veterans Affairs and the Department of Health and Human Services: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Clinicaltrial.gov Registration Number: NCT03033901.

Objective To describe the rates and causes for rehospitalization over 10 years after moderate-severe traumatic brain injury (TBI), and to characterize longitudinal trajectories of the probability of rehospitalization using generalized linear mixed models and individual growth curve models conditioned on factors that help explain individual variability in rehospitalization risk over time. Design Secondary analysis of data from a multicenter longitudinal cohort study. Setting Acute inpatient rehabilitation facilities and community follow-up. Participants Individuals 16 years and older with a primary diagnosis of TBI. Main outcome measures Rehospitalization (and reason for rehospitalization) as reported by participants or proxy 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 (27.8% of the sample), and the rates of rehospitalization remained largely stable (22.1%-23.4%) at 2, 5, and 10 years. Reasons for rehospitalization varied over time: Orthopedic and reconstructive surgery rehospitalizations were most common in year 1, whereas general health maintenance was most common by year 2 with rates increasing at each follow-up. Longitudinal models indicate that multiple demographic and injury-related factors are associated with the probability of rehospitalization over time. Conclusions These findings can inform the content and timing of interventions to improve health and longevity after TBI.

Introduction Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions. Methods This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47). Results Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Objective To examine heterogeneity in the temporal patterns of depression and participation over the first 2 years post traumatic brain injury (TBI). Design Observational prospective longitudinal study. Setting Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone. Participants Persons with TBI (N=2307) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years post injury. Interventions Not applicable. Main Outcome Measure Patient Health Questionnaire-9 (PHQ-9) and Participation Assessment With Recombined Tools–Objective (PART-O). Results Using latent class modeling we examined heterogeneity in the longitudinal relationship between PHQ-9 and PART-O. The identified 6 classes were most distinct in terms of (1) level of PHQ-9 score and (2) association between the year 1 PART-O score and year 2 PHQ-9 score. For most participants, PART-O at year 1 predicted PHQ-9 at year 2 more than the reverse. However, there was a subgroup of participants that demonstrated the reverse pattern, PHQ-9 predicting later PART-O, who were on average, older and in the “other” employment category. Conclusions Results suggest that links between participation and depression are stronger for some people living with TBI than for others and that variation in the temporal sequencing of these 2 constructs is associated with demographic characteristics. These findings illustrate the value in accounting for population heterogeneity when evaluating temporal among outcome domains.

Background Headache after traumatic brain injury (TBI) is frequent and persistent over the first year after injury. Providers may need to focus on different symptom presentations depending on their patient's TBI severity. Objective We evaluated headache symptoms in patients with moderate-to-severe TBI compared to patients with mild TBI and examined our data from two perspectives: (1) from providers who treat individuals after TBI and manage multiple postinjury symptoms including headache, and (2) from headache specialists who see individuals after TBI to manage headache. Design Prospective enrollment of individuals after TBI with telephone follow-up at 1-year postinjury. Setting Enrollment from hospital and then community followup. Participants Three hundred forty-six individuals with moderate-to-severe TBI were enrolled during acute inpatient rehabilitation across seven TBI Model System Centers. One hundred eighty-nine individuals with mild TBI were enrolled within 1 week of injury at a single center. Intervention None. Main outcome measurements Headache frequency, headache type, pain intensity, Headache Impact Test-6 (HIT-6), and depressive symptoms measured 1 year after injury. Results Headache prevalence is high in both TBI groups. TBI providers are more likely to evaluate and treat headache from individuals sustaining a mild TBI versus moderate-to-severe TBI. Patients with mild TBI are most likely to report tension-type headache followed by migraine-type headache. The migraine-type headache has higher impact (HIT-6) and greater pain intensity. Headache specialists may encounter patients with moderate-to-severe TBI who report more frequent headache and higher average pain scores compared to patients with mild TBI. The severity of TBI was unrelated to depressive symptoms 1 year after injury, but patients with headache were significantly more likely to have higher scores. Conclusions TBI providers versus headache specialists should be aware of differences in patient symptom presentation to their respective clinics. Ongoing assessment of headache and depression over time is important following TBI of any severity.

Background OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI. Research Question This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI. Study Design and Methods This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days). Results Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764). Interpretation Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

OBJECTIVE: To examine the predictive ability of depression when considering long-term employment outcomes for individuals with moderate-to-severe TBI, after controlling for key pre-injury and injury-related variables. DESIGN: Secondary data analysis. SETTING: Community follow-up after discharge from an inpatient rehabilitation center. PARTICIPANTS: Individuals between 18 and 60 years-old with moderate-to-severe TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status. RESULTS: The prevalence of employment at 2 and 5 years post-injury was 40.3% and 44.5%, respectively. Individuals identified at depressed at 1 year were less likely to be employed at 2 years post-injury (OR=1.77; 95% CI: 1.38, 2.27; p

Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Due to challenges that include inconsistent access to follow-up care, persons with TBI being discharged from inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor reintegration into the community, family stress, and other unfavorable outcomes resulting from unmet needs. In a six-center randomized pragmatic comparative effectiveness study, the BRITE trial (Brain Injury Rehabilitation: Improving the Transition Experience, ClinicalTrials.gov NCT03422276 ), we compare the effectiveness of two existing methods for transition from IRF to community living or long-term nursing care. The Rehabilitation Discharge Plan (RDP) includes patient/family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference, for 6 months. Nine hundred patients will be randomized (1:1) to RDP or RTP, with caregivers also invited to participate and contribute caregiver-reported outcomes. Extensive stakeholder input, including active participation of persons with TBI and their families, has informed all aspects of trial design and implementation planning. We hypothesize that RTP will result in better patient- and caregiver-reported outcomes (societal participation, quality of life, caregiver well-being) and more efficient use of healthcare resources at 6-months (primary outcome) and 12-months post-discharge, compared to RDP alone. Planned analyses will explore which participants benefit most from each transition model. With few exclusion criteria and other pragmatic features, the findings of this trial are expected to have a broad impact on improving transitions from inpatient TBI rehabilitation. Trial registration ClinicalTrials.gov identifier NCT03422276

Objectives To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes. Design Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI. Setting Inpatient rehabilitation unit. Participants From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed. Interventions Not applicable. Main Outcome Measure Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI. Results Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%–93%), a specificity of 51% (95% confidence interval, 39%–64%), and a Youden Index of 0.3 (95% confidence interval, 0.2–0.5). Compared with those without TBI, those with chart review–determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes. Conclusions Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Objective To examine the role of residential neighborhood characteristics in accounting for race disparities in participation among a large sample of community-living adults with chronic spinal cord injury (SCI). Design Secondary analysis of cross-sectional survey data from the national Spinal Cord Injury Model Systems (SCIMS) database linked with national survey and spatial data. Setting SCIMS database participants enrolled at 10 collaborating centers active in follow-up between 2000 and 2014. Participants The sample consisted of persons with SCI (N=6892) in 5441 Census tracts from 50 states and the District of Columbia. Intervention Not applicable. Main Outcome Measure The Craig Handicap Assessment and Reporting Technique was used to measure full participation across 4 domains: physical independence, mobility, occupation, and social integration. Results Racial minority groups had lower odds of reporting full participation relative to whites across all domains, suggesting that blacks and Hispanics are at risk for poorer community reintegration after SCI. Neighborhood characteristics, notably differences in socioeconomic advantage, reduced race group differences in the odds of full occupational and social integration, suggesting that the race disparities in community reintegration after SCI are partially attributable to variation in the economic characteristics of the places where people live. Conclusions This investigation suggests that addressing disadvantage at the neighborhood level may modify gaps in community participation after medical rehabilitation and provides further support for the role of the environment in the experience of disability.

Sleep problems are common in spinal cord injury (SCI) and multiple sclerosis (MS). However, the degree to which sleep problems differ between these distinct clinical populations has not been evaluated. In this study, we examined self-reported sleep problems in individuals with SCI and those with MS, and compared these clinical groups on the Medical Outcomes Study Sleep Scale (MOS-SS).Participants were 1,677 individuals (SCI = 581; MS = 1,096) enrolled in longitudinal study of self-reported health outcomes in SCI and MS. Univariate and multivariate analysis of covariance examined group differences on global sleep problems and domain-specific subscales of the MOS-SS.Individuals with SCI reported an average of 30 fewer min of sleep per night (Sleep Quantity subscale) and significantly greater difficulty initiating and maintaining sleep (Sleep Disturbance subscale) compared to individuals with MS. However, groups did not differ on global sleep problems (Sleep Problems Index 9).Although global sleep problems are more common in SCI and MS than in the general population, these groups exhibit differing sleep problem profiles, and thus may require unique treatment approaches to address the specific domains of sleep affected. For individuals with SCI, an additional focus on increasing sleep quantity and reducing sleep disruptions may be warranted.

To determine the number and type of longitudinal depression trajectories during the first year after spinal cord injury (SCI) and to identify baseline predictors of these trajectories.Cohort study.Rehabilitation and postacute community settings.Of 168 consecutive admissions to inpatient rehabilitation for acute SCI, 141 (115 men, 26 women) patients were enrolled in a randomized controlled trial telephone follow-up intervention, which showed no outcome differences, and completed assessments on at least 2 of the 4 follow-up occasions (3, 6, 9, and 12 months after SCI). Participants were on average 41 years old, most were non-Hispanic (96%) and white (86%), and 61.7% had tetraplegia.Data were drawn from the ineffective randomized controlled trial.Patient Health Questionnaire-9 (PHQ-9).Unconditional linear latent class growth analysis models of PHQ-9 total scores revealed an optimal 3-class solution: stable low depression (63.8%), mild to moderate depression (29.1%), and persistent moderate to severe depression (7.1%). Preinjury mental health history and baseline pain, quality of life, and grief predicted class membership.The modal response to SCI was stable low depression, whereas persistent moderate to severe depression primarily represented a continuation or relapse of preinjury depression. This line of research has the potential to improve identification of subgroups destined for poor outcomes and to inform early intervention studies.