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Objective To provide a systematic review of published interventions for posttraumatic brain injury fatigue (PTBIF). Methods PubMed and OneSearch were systematically searched for PTBIF interventions published between January 1, 1989, and March 31, 2019. Search results were evaluated for inclusion based on an abstract and full-text review. Inclusion criteria were (1) an investigation of an intervention, (2) participant sample including individuals with traumatic brain injury (TBI), (3) report of fatigue outcome data among individuals with TBI, and (4) articles available in English, Spanish, French, German, Afrikaans, or Dutch. A risk of bias assessment was conducted on all included publications. Results The search resulted in 2343 publications, with 37 meeting inclusion criteria for this review. Categories of PTBIF interventions were pharmacological (n = 13), psychological (n = 9), exercise-based (n = 4), complementary alternative medicine (n = 5), electrotherapeutic (n = 3), and multimodal (n = 3). Only methylphenidate, modafinil, and cognitive behavioral therapy interventions included multiple cohorts. Pharmacological and psychological interventions represented the groups with the lowest risk of bias. Conclusions This review includes 37 studies, with 21 studies published after 2014. Methylphenidate and melatonin were the only pharmacological agents found to reduce fatigue in randomized controlled trials. Creatine given to children prospectively at onset of injury reduced fatigue at follow-up. Walking and water aerobics were effective exercise interventions in isolated randomized controlled studies. One multimodal study of children after concussion was more effective at reducing fatigue and postconcussion symptoms than community standard of care. Other interventions had equivocal results. Overall, more work remains to understand and develop treatments for PTBIF.

Fatigue is one of the most commonly reported sequelae after traumatic brain injury (TBI). This study evaluated the impact of a graduated physical activity programme on fatigue after TBI. Using a prospective randomised single-blind crossover design, 123 individuals with TBI, over the age of 18, were enrolled. Interventions included a home-based walking programme utilising a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Nutritional counselling with the same schedule of coaching calls served as the control condition. Main outcome measures included: the Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI) Fatigue Scale Overall Severity Index Score, and the Multidimensional Fatigue Inventory (MFI). Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total, and MFI General scores. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash out period (36 weeks) as measured by the BNI Overall. The study suggests that walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.

Supplemental Digital Content is Available in the Text., Objective: To use a patient-centered approach or participatory action research design combined with advanced psychometrics to develop a comprehensive patient-reported outcomes (PRO) measurement system specifically for individuals with traumatic brain injury (TBI). This TBI Quality-of-Life (TBI-QOL) measurement system expands the work of other large PRO measurement initiatives, that is, the Patient-Reported Outcomes Measurement Information System and the Neurology Quality-of-Life measurement initiative. Setting: Five TBI Model Systems centers across the United States. Participants: Adults with TBI. Design: Classical and modern test development methodologies were used. Qualitative input was obtained from individuals with TBI, TBI clinicians, and caregivers of individuals with TBI through multiple methods, including focus groups, individual interviews, patient consultation, and cognitive debriefing interviews. Item pools were field tested in a large multisite sample (n = 675) and calibrated using item response theory methods. Main Outcomes Measures: Twenty-two TBI-QOL item banks/scales. Results: The TBI-QOL consists of 20 independent calibrated item banks and 2 uncalibrated scales that measure physical, emotional, cognitive, and social aspects of health-related quality of life. Conclusions: The TBI-QOL measurement system has potential as a common data element in TBI research and to enhance collection of health-related quality-of-life and PRO data in rehabilitation research and clinical settings.

OBJECTIVE:: To assess mortality, life expectancy, risk factors, and causes of death by age groups among persons who received inpatient traumatic brain injury (TBI) rehabilitation. DESIGN:: Prospective cohort study. SETTING:: The TBI Model Systems. PARTICIPANTS:: 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. INTERVENTIONS:: Not applicable. MAIN OUTCOME MEASURES:: Standardized mortality ratio, life expectancy, and cause of death. RESULTS:: Moderate-severe TBI increases risk of mortality compared with the general population in all age groups, with the exception of those 85 years or older at the time of injury. Teenagers to middle-aged adults are at particular risk. Risk factors for death varied by age group and included gender, marital and employment status, year and cause of injury, and level of disability. External causes of death predominate in younger groups. For the youngest male participants in the sample, longevity was reduced up to 16 years. CONCLUSION:: Risk factors and causes of death varied considerably by age group for individuals with moderate-severe TBI who were receiving acute care rehabilitation. Moderate-severe TBI is a chronic health condition. Language: en

Define associations between post-traumatic brain injury (TBI) fatigue and abnormalities in neuroendocrine axes, sleep, mood, cognition and physical functioning.Survey.Large community hospital-based rehabilitation centre.Convenience sample of 119 individuals at least 1 year post-TBI.Multidimensional Assessment of Fatigue (MAF); Fatigue Severity Scale (FSS); neuroendocrine assessments-growth hormone (GH) reserve, thyroid, cortisol and testosterone levels; visual analogue pain rating; Pittsburgh Sleep Quality Index; Beck Depression Inventory-II; Disability Rating Scale; Craig Handicap Assessment and Reporting Technique; Neurobehavioural Functioning Inventory.Fifty-three per cent reported fatigue on the MAF and one-third on the FSS; 65% were found to have moderate/severe GH deficiency; 64% had adrenal insufficiency (low fasting cortisol); 12% had central hypothyroidism; and 15% of men had testosterone deficiency. Pituitary dysfunction did not correlate with fatigue or other symptoms. Predictors of MAF total scores were female gender, depression, pain and self-assessed memory deficits. Predictors of FSS scores were depression, self-assessed motor deficits and anti-depressant usage.Robust correlates of fatigue were gender, depression, pain and memory and motor dysfunction. Investigation of post-TBI fatigue should include screening for depression, pain and sleep disturbance. There was no correlation between pituitary dysfunction and fatigue; however, the relatively high prevalence of hypothyroidism and adrenal dysfunction suggests screening for these hormone deficiencies.

Describe physical impairment at rehabilitation admission and 1-year after moderate-to-severe traumatic brain injury.Prospective longitudinal multi-centre descriptive analysis.Physical examination variables were analysed for all subjects in the Traumatic Brain Injury Model Systems database from 1988-2002 that had data both at rehabilitation admission and at 1 year.Standing balance was more commonly and severely impaired at admission (82% of sample impaired) and 1 year (24% impaired) compared to other examination variables. Sitting balance was impaired in 52% of the sample at admission, largely resolving (5% abnormal) by 1 year. The profile of impaired strength, coordination and tone was similar among the four limbs. Impaired limb strength was most common and persistent over the study period compared to coordination and tone, but strength was normal in greater than 80% of subjects at 1 year. Dysphagia present at admission (40% of sample) largely resolved by 1 year (0.4% unable to swallow). Impairment in audition and vision was uncommon and changed little during the study period.Acute impairment was present in all variables. A minority of the sample had detectable impairment at 1 year. Standing balance was most severely and persistently impaired.

Frankel JE, Marwitz JH, Cifu DX, Kreutzer JS, Englander J, Rosenthal M. A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay. Objective To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI). Design Retrospective collaborative study. Setting Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research–designated Traumatic Brain Injury Model Systems (TBIMS) centers. Participants A sample of 273 older patients (≥55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included. Intervention Inpatient interdisciplinary brain injury rehabilitation. Main Outcome Measures Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition. Results One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients. Conclusions Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.

Background: The incidence of late posttraumatic seizures (LPTS) in individuals with traumatic brain injury (TBI) ranges anywhere from 5% to 18.9% in civilian populations up to 32% to 50% in military personnel. Objective: This article reviews the current knowledge about the incidence and prevalence of LPTS following a TBI, the risk factors for developing LPTS, and the options available for preventing the development of LPTS. Methods: The psychosocial ramifications of LPTS following a TBI have not been well explored. As a result, the psychosocial findings from the current literature on epilepsy will be reviewed with the hope that the need for future TBI outcomes research to investigate the impact of LPTS following a TBI or, at least, to include LPTS as a potential contributing factor will be recognized.

Cifu DX, Kreutzer JS, Kolakowsky-Hayner SA, Marwitz JH, Englander J. The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: a multicenter analysis. Arch Phys Med Rehabil 2003;84:1441–8. Objectives To identify factors relating to the intensity of rehabilitation services received and to ascertain the relation between injury outcomes, demographics, types of therapy, and the intensity of rehabilitation services provided. Design A multicenter, prospective, nonrandomized study with inpatient rehabilitation data collected between 1989 and 1996. Setting Three 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, and inpatient rehabilitation. Participants A total of 491 consecutively enrolled patients with a mean age ± standard deviation of 34.3±15.88 years recruited from 3 medical centers. To be included in the study, patients must have been at least 16 years of age, have presented to the emergency department within 24 hours of injury, and have received acute care and inpatient rehabilitation. Interventions Patients received comprehensive medical care along with a combination of rehabilitative therapies, including physical, occupational, psychologic, and speech therapy. Main outcome measures Therapy intensity; levels of functional independence, cognitive function, functional gain, and treatment efficiency, as indicated by the FIM™ instrument; rehabilitation length of stay (LOS); and charges. Results Age predicted the intensity of both psychologic ( P P P P P P Conclusions This study is among the first multicenter efforts to examine the potential benefits of individual therapy services. Findings support assertions that increased therapy intensity, particularly physical and psychologic therapies, enhances functional outcomes.

Englander J, Bushnik T, Duong TT, Cifu DX, Zafonte R, Wright J, Hughes R, Bergman W. Analyzing risk factors for late posttraumatic seizures: a prospective, multicenter investigation. Arch Phys Med Rehabil 2003;84:365-73. Objectives: To ascertain the natural history and to stratify risks for the development of late posttraumatic seizures in individuals with moderate to severe traumatic brain injury (TBI). Design: Prospective, observational study of individuals with TBI admitted to 4 trauma centers within 24 hours of injury. Setting: Four tertiary care trauma centers in urban areas. Participants: A total of 647 individuals ([ge ]16y) with any of the following abnormal computed tomography (CT) scan findings: extent of midline shift and/or cisternal compression or presence of any focal pathology (eg, punctate, subarachnoid, or intraventricular hemorrhage; cortical or subcortical contusion; extra-axial lesions) during the first 7 days postinjury or best Glasgow Coma Scale (GCS) score of [le ]10 during the first 24 hours post-TBI. Subjects were enrolled from August 1993 through September 1997 and followed for up to 24 months, until death or their first late posttraumatic seizures. Interventions: Not applicable. Main Outcome Measures: Cumulative probability, relative risk, and survival analyses were used to stratify risks for development of late postttraumatic seizures on the basis of demographic factors, etiology of injury, initial GCS, early posttraumatic seizures, time post-TBI, types of intracerebral lesion by CT scan, and number and types of intracranial procedures. Results: Sixty-six individuals had a late posttraumatic seizures; 337 had no late posttraumatic seizures during full 24-month follow-up; 167 had no late posttraumatic seizures during time followed ([lt ]24mo); and 54 were placed on anticonvulsants without a late posttraumatic seizures, whereas 23 died before their first late posttraumatic seizures. The highest cumulative probability for late posttraumatic seizures included biparietal contusions (66%), dural penetration with bone and metal fragments (62.5%), multiple intracranial operations (36.5%), multiple subcortical contusions (33.4%), subdural hematoma with evacuation (27.8%), midline shift greater than 5mm (25.8%), or multiple or bilateral cortical contusions (25%). Initial GCS score was associated with the following cumulative probabilities for development of late posttraumatic seizures at 24 months: GCS score of 3 to 8, 16.8%; GCS score of 9 to 12, 24.3%; and GCS score of 13 to 15, 8.0%. Conclusions: Stratification by CT scan findings and neurosurgical procedures performed were the most useful findings in defining individuals at highest risk for late posttraumatic seizures. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Foxx-Orenstein A, Kolakowsky-Hayner S, Marwitz JH, Cifu DX, Dunbar A, Englander J, Francisco G. Incidence, risk factors, and outcomes of fecal incontinence after acute brain injury: findings from the Traumatic Brain Injury Model Systems national database. Arch Phys Med Rehabil 2003;84:231-7. Objective: To investigate the incidence, risk factors, and outcome in patients with fecal incontinence after acute brain injury. Design: A retrospective study of the incidence of and risk factors contributing to fecal incontinence, and outcomes at admission to and discharge from inpatient rehabilitation and at 1-year follow-up. Setting: Medical centers in the federally sponsored Traumatic Brain Injury Model Systems (TBIMS). Participants: A total of 1013 consecutively enrolled rehabilitation inpatients from 17 TBIMS centers who were admitted to acute care within 24 hours of traumatic brain injury and seen at 1-year postinjury between 1990 and 2000. Interventions: Not applicable. Main Outcome Measures: Incidence of fecal incontinence, length of coma, length of posttraumatic amnesia (PTA), admission Glasgow Coma Scale (GCS) score, length of stay (LOS), FIM[trade ] instrument scores, disposition at discharge and follow-up, and incidences of pelvic fracture, frontal contusion, and urinary tract infection (UTI). Results: The incidence of fecal incontinence was 68% at admission to inpatient rehabilitation, 12.4% at rehabilitation discharge, and 5.2% at 1-year follow-up. Analysis of variance and chi-square analyses revealed statistically significant associations between the incidence of fecal incontinence at rehabilitation admission and admission GCS score, length of coma and PTA, LOS, and incidence of UTI and frontal contusion. Fecal incontinence at rehabilitation discharge was significantly associated with several variables, including age, discharge disposition, admission GCS score, length of coma, PTA, LOS, FIM scores, and incidence of pelvic fracture and frontal contusion. Significant associations were also found between fecal incontinence at 1-year follow-up and age, discharge and current 1-year disposition, admission GCS score, length of coma, LOS, FIM scores, and incidence of UTI ( P [lt ].05). Although logistic regression analyses were significant ( P [lt ].001), and predicted continence with 100% accuracy, demographics, injury characteristics, medical complications, and functional outcomes did not predict incontinence at discharge and at 1-year follow-up. Conclusions: Fecal incontinence is a significant problem after brain injury. Certain factors may increase its likelihood. Further studies evaluating mechanisms of fecal incontinence and treatment or control interventions would be useful. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective: To determine whether a 12-week home-based walking programme can decrease perceived stress and depressive symptoms in persons with a traumatic brain injury (TBI).Community- and home-based.Sixty-nine participants with a TBI.Comparative effectiveness cross-over design with random assignment to treatment sequence and blinded post-hoc assessment of outcome where participants completed a 12-week walking intervention and a nutrition education module. The walking intervention utilized pedometers to track the amount of steps each participant walked daily. With the assistance of an assigned coach, weekly goals were given with the intent of increasing the amount of walking that the participant was initially completing. The nutrition control group was created to offset the impact of the coaching calls.Measurement of perceived stress and depressive symptoms was completed through the use of the Perceived Stress Scale (PSS) and Center for Epidemiological Studies-Depression (CES-D). These measures were collected at three time points: baseline and following each 12-week intervention.RESULTS indicated that both perceived stress and depression symptoms significantly improved following the walking intervention.While limitations existed with the study, it is evident that walking can be used as an efficient and cost-effective tool to manage perceived stress and depressive symptoms in persons who have sustained a TBI.

OBJECTIVE To evaluate how demographics, measures of injury severity, and acute care complications relate to sitting and standing balance in patients with traumatic brain injury (TBI). DESIGN Multicenter analysis of consecutive admissions to designated TBI Model Systems of Care (TBIMS). SETTING Ten National Institute for Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. PARTICIPANTS 908 adults with TBI were included in the study. MAIN OUTCOME MEASURES Sitting and standing balance were assessed within 72 hours of admission to inpatient rehabilitation. RESULTS Age less than 50 years had a significant association with normal sitting and standing balance (P =.001 and.05, respectively). Measures of severity of traumatic brain injury, including admission Glasgow Coma Score, length of posttraumatic amnesia (PTA), length of coma, and acute care length of stay were each significantly related to impaired sitting and standing balance ratings (P

Objectives: To identify possible risk factors that may predispose individuals to violent traumatic brain injury (TBI) and to determine the effect of etiology of injury on outcomes. Study Design: Prospective, longitudinal multicenter study. Setting: TBI Model Systems (TBIMS) located at Wayne State University/Rehabilitation Institute of Michigan, Detroit, MI; The Institute for Rehabilitation and Research, Houston, TX; Medical College of Virginia, Richmond, VA; and Santa Clara Valley Medical Center, San Jose, CA. Subjects: Individuals treated in the four TBIMS programs between 389 and 996 who met the criteria for inclusion in the TBIMS National Database and for whom the etiology was known ( n = 812). Main Outcome Measures: Functional Independence Measure, Alcohol Quantity Frequency Variability Index, Community Integration Questionnaire. Results: Individuals who incur violence-related TBI tend to be male, nonwhite, unmarried, living alone, less educated, and unemployed at time of injury. They tend to have less severe brain injuries and better motor function at the time of admission to inpatient rehabilitation. At 1 year postinjury, they score lower on community integration measures; however, no difference exists in functional status. Etiology of injury was found to only play a minor role in the prediction of social and productive integration at 1 year postinjury. Conclusions: Survivors of violent and nonviolent TBI have similar functional outcomes; however, they differ in preinjury and postinjury socio-economic characteristics, injury severity, and postinjury community integration. Socio-economic factors appear to play a large role in the risk for violent injury and in community integration following injury.

The literature is replete with studies investigating predictors of outcomes in traumatic brain injury. Few, however, have addressed the pre morbid life events and behaviors that may significantly impact the physical, behavioral, cognitive, and/or psychosocial and vocational status of individuals after a traumatic brain injury (TBI). Findings of studies on premorbid history are reviewed and data are presented on a sample of 82 cases on which premorbid psychosocial information, severity of initial injury and outcome status were obtained. Cases were dichotomized into groups at high risk and at low risk for TBI, based on premorbid history. High risk and low risk groups were comparable in the severity of initial injury. Outcomes were defined by the Functional Independence Measure and the Disability Rating Scale scores at 1 year after injury. No differences were found in FIMTM or DRS scores between those with and without premorbid learning disability, psychiatric history, incarcerations, arrests, academic difficulties, or substance abuse. Explanations for the lack of significant differences are discussed. Based on experience in completing this study, a screening tool incorporating documentation of a number of pre morbid factors that might impact status at outcome is presented.

To better characterize, describe and highlight issues that individuals with TBI and active LPTS may face in their daily lives.Prospective multi-centre mixed method qualitative and quantitative interview.Twenty-five individuals, 5-13 years post-injury, who had reported having LPTS and TBI.Disability Rating Scale (DRS); Supervision Rating Scale (SRS); Glasgow Outcome Scale-Extended (GOS-E); Perceived Stress Scale (PSS); Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF) sub-scales: Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration; and Craig Hospital Inventory of Environmental Factors (CHIEF); and qualitative interview questions pertaining to management of the seizure disorder and its effect on the individual's health, function, community integration and participation.Data are presented regarding seizure activity and management; return to driving post-seizure; coping and participation; and standardized outcome measures.Individuals with TBI and LPTS are at a double-barrelled disadvantage regarding ongoing physical, cognitive, psychosocial and reintegration issues following brain injury and epilepsy. Clearer clinical guidelines and treatment strategies need to be developed to help ameliorate these ongoing issues. Additional research is needed to identify what the rehabilitation community can do to continue to facilitate people living safely and independently.

Objective: To determine whether minority status affected short-term and 1-year functional outcome and community integration for patients with traumatic brain injury (TBI) in the TBI Model Systems National Data Base. Design: Prospective study, consecutive sample. Setting: Four tertiary care rehabilitation centers. Patients: Five hundred and eighty-six patients with TBI admitted to one of four TBI Model Systems programs from February 1989 through June 1995. Inclusion criteria for the study included evidence of a TBI, admission to the system hospital emergency department within 8 hours of injury, 19 years of age or older, and acute care and inpatlent rehabilitation within the system hospitals. Information was collected for demographics such as race, age, gender, education, employment status, marital status, and data related to the injury such as injury severity, etiology of injury, and payer source. Over half of the sample was white (53.4%) with the 46.6% of minorities composed of blacks (37.2%), Hispanics (7.3%), and Asians (2.0%). Main Outcome Measures: Functional outcome was measured with the Functional Independence Measure (FIM), Disability Rating Scale (DRS), and Community Integration Questionnaire (CIQ). The FIM and DRS were measured at inpatient rehabilitation admission, discharge, and 1 year post injury. The CIQ total score and subscale scores for Home Integration, Social Integration, and Productivity were obtained at 1-year post injury. It was hypothesized that minority status would not predict functional outcome after acute rehabilitation but would predict functional outcome and community integration at 1 year post injury. Results: There were no significant differences between whites and minorities for DRS and FIM scores at acute rehabilitation discharge. There were also no significant differences between whites and minorities on FIM scores 1 year post injury, but there were significant differences between whites and minorities on the Social Integration and Productivity subscales and total score of the CIQ. Multiple regression indicated that minority status predicted functional outcome for CIQ total score (r=-.28) and two subscales, Social Integration (=-.28) and Productivity ( r= -.23) even after controlling for etiology, severity of injury, age, gender, and functional status at rehabilitation discharge. Conclusions: Although minority status does not negatively impact recovery of basic mobility and daily living skills, it may impact long-term outcome related to community integration as measured by productivity and social integration. Greater outreach and access to postdischargc services and support may be needed to optimize community integration outcomes. Further studies are needed to determine how best to serve the needs of this segment of the population with TBI

OBJECTIVE: : To compare and contrast the levels of impairment, disability, and community participation of individuals with traumatic brain injury (TBI) with or without late posttraumatic seizures (LPTS). DESIGN: : Prospective survey study. SETTING: : Community. PARTICIPANTS: : Two groups of 91 individuals with TBI, with and without LPTS, were enrolled in the TBI Model Systems National Database between 1989 and 2002 and interviewed at years 1, 2, and 5 postinjury. INTERVENTIONS: : Not applicable. MAIN OUTCOME MEASURES: : Demographic, injury severity, productivity, and psychosocial outcomes. RESULTS: : The majority of the demographic and productivity outcomes up to 5 years postinjury were similar between individuals in the LPTS and non-LPTS groups. Both the LPTS and non-LPTS groups showed an increasing percentage of individuals who began to live alone after the first year postinjury and a decreasing percentage of individuals who were living with family members at 5 years postinjury compared with the first year post-TBI. A higher percentage of individuals in the LPTS group reported using more dependent forms of transportation such as riding with others or using public transportation. Individuals in the LPTS group had higher Disability Rating Scale scores at all time points, denoting greater functional disability, than individuals in the non-LPTS group, despite the 2 groups having similar Disability Rating Scale scores at discharge from rehabilitation. Satisfaction With Life Scale scores showed no changes over time but were significantly different between both groups at all time points, with individuals in the LPTS group reporting lower Satisfaction With Life Scale score than individuals in the non-LPTS group. CONCLUSIONS: : It does appear that the development of LPTS following a TBI is associated with poorer functional and psychosocial outcomes in the first 5 years after injury. It remains to be determined whether there are other factors that also may account for these differences and that may be amenable to intervention. Language: en

The present study investigated the possible role of a number of pre- peri-, and post-traumatic factors in the experience of post-concussion syndrome (PCS). These factors included: (1) history of premorbid risk factors, (2) severity of injury, and (3) post-morbid functioning and environmental factors. Subjects were 55 persons with mild brain injury. PCS was defined in terms of the severity and impact of 'late-onset' symptoms. Pre- and peri-traumatic factors were not associated with level of PCS symptom impact. Among post-traumatic factors, only level of psychological distress was strongly associated with impact level. The results suggest the importance of psychological factors in prolonged PCS.

To understand the course of changes in function and need for assistance in the chronic stages of TBI; and to identify factors associated with these changes.Longitudinal review of participants in the TBI Model Systems Database, who have been prospectively followed for at least 10 years.Four hundred and seventy-eight individuals with TBI that occurred between 25 October 1988 and 31 December 1998, enrolled in the TBI Model Systems National Database, eligible for 10-year follow-up when data was extracted, with completed data collection at either year 1 or 2 and year 10.Significant between age group differences were found for FIM toileting, bladder, bowel, toilet transfers, locomotion, problem-solving and memory; SRS; DRS level of functioning, employability and total; and GOS. With regard to functional independence, there were significant differences by age category for all FIM components except memory. Significant differences were noted for age category and level of dependence as measured by the DRS (LOF 1.5-5) and GOS (GOS 2-4). Supervision needs significantly increased as a function of age. Significant differences were found for diminished function over time. Significant differences were noted for residence at 10 years post-injury.For those individuals that survive to 10 years post-TBI, age is a major factor in requiring assistance of another person for supervision as well as assistance in basic self-care, continence and mobility.

The first section of this article discusses the principal clinical components of a model system of care for traumatic brain injury (TBI) or spinal cord injury (SCI). The next section, "The Future of Model Systems", addresses the advantages of such a system, as related to the changing health care climate and predicted future directions of health care in the United States. The need for innovative approaches to rehabilitation is upon us. In addressing this need, the last section, "Recommendations for Change", outlines cost-effective measures for providing rehabilitation services to our clientele.

This article describes the development and characteristics of the database that supports the research and demonstration aspects of the traumatic brain injury (TBI) model systems project sponsored by the National Institute on Disability and Rehabilitation Research. Criteria for inclusion of patients

This study documents the medical complications and associated injuries that occurred in persons admitted for rehabilitation in the five Traumatic Brain Injury (TBI) Model System projects. The incidence of specific intracranial hemorrhages, medical complications, and associated injuries are discussed. Two thirds of these individuals had one or more intracranial hemorrhages, the most common being subdural (32%) and subarachnoid (27%) hemorrhages. Persons with one or two intracranial hemorrhages were found to have significantly longer lengths of stay (LOS) in acute care compared to those with no hemorrhahges. One or more intracranial hemorrhages were found in persons injured by a fall (84%), while riding a bicycle (81%), while walking (76%), and by assault (73%). Of the nonhemorrhagic cerebral complications/problems investigated, seizures, cerebrospinal fluid (CSF) leak, and hydrocephalus were found to be related to extended LOS in acute care. Seizures were reported in 17% of patients, with 10% of all patients exhibiting a seizure within the first 24 hours postinjury. The extracerebral complications associated with longer LOS in acute care were respiratory failure, pneumonia, urinary tract infection, soft-tissue infection (STI), coagulopathy, renal failure, and septic shock. Persons injured in all-terrain vehicles, pedestrian/auto encounters, gunshot wounds to the head, and automobile crashes were more likely to have extracerebral complications than those injured by other causes. Fractures and cranial nerve injuries were the most common associated injuries. A larger proportion of persons injured in motor vehicle crashes, pedestrian/auto encounters, and bicycle accidents had associated injuries than those injured by other mechanisms.

One of the problems that can occur after a traumatic brain injury (TBI) is seizures. Although most people who have a brain injury will never have a seizure, it is good to understand what a seizure is and what to do if you have one. Most seizures happen in the first several days or weeks after a brain injury. Some may occur months or years after the injury. About 70-80% of people who have seizures are helped by medications, and can return to usual activities. Rarely, seizures can make you much worse or even cause death.

Elderly individuals are second only to young adults among those most likely to sustain traumatic brain injury. Falls, pedestrian accidents, and low-speed motor vehicle accidents are the most common causes of traumatic brain injury in the elderly and often result in focal contusions or subdural or intraparenchymal hematomas. Individuals with coma lasting less than 6 hours, a supportive social network, and absence of substance abuse are likely to have good outcomes, whereas those living alone and with prolonged coma and chronic alcohol use often have poor outcomes. Slower recovery, a higher rate of medical complications, and payer limitations make necessary careful assessment and imaginative use of home and other settings for treatment. Intensive rehabilitation can be effective with selected elderly individuals.

Background Deep venous thrombosis (DVT) is a major cause of mortality and morbidity after traumatic brain injury (TBI). There is no consensus regarding appropriate screening, prophylaxis, or treatment during acute rehabilitation. Methods This prospective observational study evaluated prophylactic anticoagulation during rehabilitation in patients with TBI aged 16 years or older admitted to 12 TBI Model Systems rehabilitation centers (July 2004-December 2007). After propensity score stratification within center, the odds ratio associated with incidence of symptomatic DVT or pulmonary embolism (PE) for patients who did and did not receive prophylactic anticoagulation was estimated using conditional logistic regression in patients who were not screened for DVT on rehabilitation admission or who screened negative; the analysis was repeated in these two subgroups. Results Patients with identified DVTs at rehabilitation admission (n = 266) were excluded, leaving 1,897 patients: 1,002 screened negative, 895 unscreened; 932 received prophylactic anticoagulation, and 965 did not. Symptomatic DVT/PE was detected in 32 patients (15 of 932 [1.6%] with prophylaxis, 17 of 965 [1.8%] without). After propensity score adjustment, the odds ratio (95% confidence interval) for symptomatic DVT/PE with prophylaxis versus no prophylaxis was 0.80 (0.33-1.94) in the full analytic population and 0.46 (0.12-1.84) in the screened-negative subgroup. The only probable venous thromboembolism-related death occurred in the prophylactic anticoagulation group. Fewer new/expanded intracranial hemorrhages occurred among patients who received prophylactic anticoagulation. Conclusions Prophylactic anticoagulation during rehabilitation seemed safe for TBI patients whose physicians deemed it appropriate, but did not conclusively reduce venous thromboembolism. Given the number of DVTs present before rehabilitation, screening and prophylaxis during acute care may be more important.

The objective of this study was to examine the mortality rates in individuals with traumatic brain injury (TBI) who were classified as having experienced late post-traumatic seizures (LPTS) in the first 2 years post-TBI compared to those who were seizure-free (non-LPTS). Participants were a pooled sample (n = 508) from two studies which enrolled individuals with TBI who were injured between March 31, 1992 and December 20, 1999. The first sample was made up of individuals enrolled in a study of risk factors for LPTS development; the second sample was composed of individuals enrolled in the TBI National Database from a single rehabilitation center. Seventy-one (14%) participants had LPTS, of which 27% had died at 8-15 years post-injury, as compared to 10% of non-LPTS participants. Individuals with LPTS died at a younger age (54.1 versus 67.7 years; p = 0.01), but there were no statistically significant differences in either time from date of injury to death or highest GCS score in the first 24 h. Causes of death were variable and not specifically related to epilepsy. Of those with LPTS, risk factors for death include advanced age at time of injury and presence of subdural hematoma. The higher mortality rate and death at younger age with variable causes in TBI individuals with LPTS warrant close medical evaluation and monitoring of these individuals, particularly accessibility and compliance with ongoing general medical care, and education of primary care colleagues of the unique needs of this at-risk population.

To correlate deficient pituitary function with life satisfaction and functional performance in subjects with a recent history of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH).Cross-sectional study.Eighteen subjects with TBI and 16 subjects with SAH underwent pituitary hormonal and functional assessments 5-12 months following the event. Adrenal reserve was assessed with a 1 mcg cosyntropin stimulation test and growth hormone deficiency (GHD) was diagnosed by insufficient GH response to GHRH-Arginine stimulation. Assessments of life satisfaction and performance-function included the Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART) and the Mayo Portland Adaptability Inventory-4 (MPAI-4).Hypopituitarism was present in 20 (58.8%) subjects, including 50% with adrenal insufficiency. Hypothyroidism correlated with worse performance on SWLS and CHART measures. GHD was associated with poorer performance on CHART and MPAI-4 scale.In this series of subjects with history of TBI and SAH, hypothyroidism and GHD were associated with diminished life satisfaction and performance-function on multiple assessments. Further studies are necessary to determine the appropriate testing of adrenal reserve in this population and to determine the benefit of pituitary hormone replacement therapy on function following brain injury.

Fatigue is a well-recognized issue for individuals with traumatic brain injury (TBI). This prospective study examined the rate and types of fatigue that are experienced by a cohort of individuals with TBI within the first 2 years, using a multidimensional fatigue scale. The impact of factors such as demographics, injury severity indices, and concomitant psychosocial variables was also examined. Using 2 measures of overall fatigue, 16%-32% at Year 1 and 21%-34% at Year 2 reported significant levels of fatigue. Fatigue did not appear to change between 1 and 2 years post-TBI. Sleep quality was the most prevalent concomitant disturbance followed by depression and pain.

This study used a prospective longitudinal design to quantify fatigue and associated factors during the first 2 years after traumatic brain injury (TBI). Fifty-one individuals were assessed at 3 time points: within the first 6, 12, and 18-24 months after TBI. Self-reported fatigue improved during the first year, as did pain, sleep quality, cognitive independence, and involvement in productive activity. Further changes up to 2 years after TBI were not observed. The subset of individuals who reported significant increases in fatigue over the first 2 years demonstrated poorer outcomes in cognition, motor symptoms, and general functioning than those with decreased or stable fatigue.

Evaluate the association between neuroendocrine findings and fatigue after traumatic brain injury (TBI) Research design: Prospective, observational.Sixty-four individuals at least 1 year post-TBI underwent neuroendocrine testing including thyroid, adrenal, gonadal axes and growth hormone (GH) after glucagon stimulation with assessment of fatigue using the Global Fatigue Index (GFI) and the Fatigue Severity Scale (FSS).GFI and FSS scores were significantly higher within this sample compared to published control data. At least one pituitary axis was abnormal in 90% of participants. Higher GH levels were significantly associated with higher FSS scores. There was a noted trend between lower basal cortisol and higher scores on both the FSS and GFI.The association between higher GH levels and greater fatigue contradicted the prevailing hypothesis that post-acute TBI fatigue is associated with GH deficiency. The association between lower basal cortisol and greater fatigue was in the expected direction. While no other trends were noted, the fatigue derived from neuroendocrine abnormalities alone may be masked by fatigue induced by other factors commonly experienced following TBI. Given the high prevalence of pituitary abnormalities, screening for hypopituitarism after TBI is a reasonable recommendation. The contribution of GH deficiency to diminished quality of life post-TBI remains unclear.

Traumatic brain injury (TBI) often presents clinicians with a complex combination of clinical elements that can confound treatment and make outcome prediction challenging. Predictive models have commonly used acute physiological variables and gross clinical measures to predict mortality and basic outcome endpoints. The primary goal of this study was to consider all clinical elements available concerning a survivor of TBI admitted for inpatient rehabilitation, and identify those factors that predict disability, need for supervision, and productive activity one year after injury. The Traumatic Brain Injury Model Systems (TBIMS) database was used for decision tree analysis using recursive partitioning (n = 3463). Outcome measures included the Functional Independence Measure(), the Disability Rating Scale, the Supervision Rating Scale, and a measure of productive activity. Predictor variables included all physical examination elements, measures of injury severity (initial Glasgow Coma Scale score, duration of post-traumatic amnesia [PTA], length of coma, CT scan pathology), gender, age, and years of education. The duration of PTA, age, and most elements of the physical examination were predictive of early disability. The duration of PTA alone was selected to predict late disability and independent living. The duration of PTA, age, sitting balance, and limb strength were selected to predict productive activity at 1 year. The duration of PTA was the best predictor of outcome selected in this model for all endpoints and elements of the physical examination provided additional predictive value. Valid and reliable measures of PTA and physical impairment after TBI are important for accurate outcome prediction.

To examine the relationship between cortical lesion location and brain injury outcome. It was hypothesized that focal frontal lesions after traumatic brain injury (TBI) would result in decreased executive and memory functioning and poor community participation outcome.Three quasi-experimental, prospective studies employed a total of 643 patients with focal frontal, fronto-temporal, non-frontal or no lesions in CT scans.CT scan analysis, neuropsychological assessment, the Neurobehavioural Functioning Inventory (NFI), the Community Integration Questionnaire (CIQ).In study 1, frontal and fronto-temporal groups performed worse in executive functioning and better in constructional ability. Study 2 found no differences in neuropsychological and community re-integration measures at 1-year follow-up. Study 3 found comparable neuropsychological test score improvement across groups over 1 year.Results are consistent with previous findings and document the potential for test score improvement with rehabilitation and suggest that lesion location needs to be considered when individual rehabilitation plans are being implemented in the post-acute stage of TBI.

To examine the relation among strength, balance, and swallowing deficits, as measured on rehabilitation admission, and functional outcome at discharge and 1 year after traumatic brain injury (TBI).Multicenter analysis of consecutive admissions to designated Traumatic Brain Injury Model Systems (TBIMS) facilities.Seventeen TBIMS centers.Adults and children older than 16 years of age with TBI (N=2363) enrolled in the national database from January 1989 to November 2000.Not applicable.Transfers, locomotion, stairs, lower-body dressing, grooming, bathing, upper-body dressing, toileting, and eating as measured by the FIM instrument at acute rehabilitation discharge and at 1 year after TBI.Lower-extremity strength less than 3/5 on admission to acute rehabilitation was associated with increased need for assistance in locomotion, transfers, and lower-body dressing and less than 3/5 upper-extremity strength was associated with the need for assistance in self-care at rehabilitation discharge and at 1 year postinjury. Similar relations were found between impaired swallowing and assistance with eating, grossly impaired dynamic sitting, or standing balance and assistance with locomotion, transfers, eating, and self-care at rehabilitation discharge and at 1 year after TBI.Assessments of physical strength, swallowing ability, and dynamic balance on acute rehabilitation admission are helpful as screening tests in predicting the need for assistance of another person for mobility and self-care at rehabilitation discharge. This association remains strong at 1 year after TBI. By using this information, clinicians should initiate therapeutic interventions that optimize rehabilitation of the identified impairments and should make necessary arrangement for the patient's anticipated postdischarge needs. Further studies are necessary to delineate the amount of unique variance that these early physical examination findings contribute to outcome prediction.

To identify factors relating to the intensity of rehabilitation services received and to ascertain the relation between injury outcomes, demographics, types of therapy, and the intensity of rehabilitation services provided.A multicenter, prospective, nonrandomized study with inpatient rehabilitation data collected between 1989 and 1996.Three 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, and inpatient rehabilitation.A total of 491 consecutively enrolled patients with a mean age +/- standard deviation of 34.3+/-15.88 years recruited from 3 medical centers. To be included in the study, patients must have been at least 16 years of age, have presented to the emergency department within 24 hours of injury, and have received acute care and inpatient rehabilitation.Patients received comprehensive medical care along with a combination of rehabilitative therapies, including physical, occupational, psychologic, and speech therapy.Therapy intensity; levels of functional independence, cognitive function, functional gain, and treatment efficiency, as indicated by the FIM instrument; rehabilitation length of stay (LOS); and charges.Age predicted the intensity of both psychologic (P.001) and total therapy (P.01) services. Acute care LOS was also a significant predictor of psychologic services (P.01). Only admission motor FIM was relevant in predicting speech services intensity (P.01). Therapy intensity was predictive of motor functioning at discharge (P.001). However, therapy intensity did not predict cognitive gain (P.05).This study is among the first multicenter efforts to examine the potential benefits of individual therapy services. Findings support assertions that increased therapy intensity, particularly physical and psychologic therapies, enhances functional outcomes.

OBJECTIVE: To compare types and frequency of medical complications and comorbidities associated with violence-related penetrating traumatic brain injury (TBI) as compared to violence-related blunt TBI. METHOD: Data were collected prospectively at four medical centers participating in the TBI Model Systems (TBIMS) of Care project. A total of 317 individuals met the inclusion criteria for the TBIMS (i.e., showed evidence of a TBI, were age 16 or older, presented to the TBIMS emergency department within 24 hours of injury, and received acute and rehabilitation services within the model system). MAIN OUTCOME MEASURES: Frequency of medical complications and comorbid diseases. RESULTS: Patients with penetrating injuries suffered significantly higher rates of respiratory failure (P =.004), pneumonitis/pneumonia, (P =.002), skull fracture (P =.001), cerebrospinal fluid leak (P =.0005), and hypotonia (P =.001) than did patients with blunt injuries. Prediction of complications and comorbidities via multiple regression revealed that a penetrating violent injury and the severity of injury were independent predictors of a higher rate of medical complications, whereas age and gender did not account for unique variance in the equation. CONCLUSIONS: Penetrating injuries are associated with higher rates of certain medical complications, especially to the pulmonary and central nervous systems. Acute care physicians and physiatrists must be prepared to treat these complications more often in patients with penetrating injuries. Language: en

Hart T, Millis S, Novack T, Englander J, Fidler-Sheppard R, Bell KR. The relationship between neuropsychologic function and level of caregiver supervision at 1 year after traumatic brain injury. Arch Phys Med Rehabil 2003;84:221-30. Objectives: To evaluate distribution of levels of caregiver supervision at 1 year after traumatic brain injury, and to determine neuropsychologic predictors of supervision level. Design: Prospective longitudinal design, concurrent measurement of neuropsychologic function and supervision level. Setting: Seventeen Traumatic Brain Injury Model Systems centers. Participants: A total of 563 adults tested at 1 year postinjury; and a subgroup of 452 studied for neuropsychologic function in the absence of impairment in mobility or basic self-care, as assessed by high FIM[trade ] instrument motor scores. Interventions: Not applicable. Main Outcome Measure: Supervision level measured by scores on Supervision Rating Scale (SRS). Results: Two thirds (69%) of the sample was rated as independent of supervision. Participants without significant dysfunction on motor FIM were grouped into supervision groups differing in intensity of time commitment from caregiver (independent, moderate supervision, heavy supervision). In univariate analyses, groups differed on demographic variables (education, race, productivity prior to injury), duration of altered consciousness, and all but 1 neuropsychologic measure. A binomial regression model (complementary log-log model) revealed that supervision at 1 year was predicted by education and scores on the Trail Making Test Part B and digits backward. Conclusions: Findings confirm the importance of preinjury status and measures of working memory and cognitive flexibility in predicting functional independence after TBI. The SRS appears prone to ceiling effects in persons followed prospectively after moderate to severe TBI. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

To ascertain the association between early computed tomography (CT) scan findings and the need for assistance with ambulation, activities of daily living (ADLs), and supervision at rehabilitation discharge and at 1 year after traumatic brain injury (TBI).Prospective longitudinal design.Seventeen Traumatic Brain Injury Model Systems (TBIMS) centers.A total of 1,839 adults with TBI admitted to TBIMS trauma centers with subsequent acute rehabilitation; 849 were followed to 1 year after injury.Not applicable.Accumulated CT scan pathology from the first week after injury; FIM instrument and Disability Rating Scale at rehabilitation discharge and 1 year after injury; and Supervision Rating Scale at 1 year.Chi-square analyses showed that individuals with a midline shift greater than 5mm (lateral compression) were more likely to require the assistance of another person at discharge from acute rehabilitation with ambulation (29% vs 17%-19%, P=.02), toileting (47% vs 33%-38%, P=.05), lower-body dressing (57% vs 39%-46%, P=.015), bladder continence (32% vs 19%-23%, P=.03), and overall supervision (53% vs 44%, P=.0006) than patients with a midline shift of lesser degree. At 1 year, 57% of patients with a midline shift greater than 5mm on acute CT scans were being supervised in the home versus 30% to 39% of those with a shift of lesser degree (P=.003); there were no significant differences in the percentages of those needing assistance for ambulation or ADLs. The association of subdural hematoma with ambulation, self-care, and supervision needs was related to the degree of midline shift but not to the presence of subdural hematoma. Individuals with subcortical contusions were more likely to require assistance at rehabilitation discharge for ambulation (32% vs 18%, P.0001), lower-body dressing (61% vs 44%), toileting (52% vs 35%), bladder continence (34% vs 22%), and overall supervision (61% vs 44%) than those without subcortical contusions (P.0001). At 1 year, individuals with acute subcortical contusions were more likely to need assistance with ambulation (15% vs 8%, P=.004) and stair climbing (15% vs 9%, P=.03). Those with bilateral frontal (54% vs 46%, P=.009) or bilateral temporal (58% vs 46%, P=.03) contusions were more likely to need assistance with overall supervision at rehabilitation discharge, compared with those with unilateral or no cortical contusions.The presence of either a midline shift greater than 5mm or a subcortical contusion on acute CT scans is associated with a greater need of assistance with ambulation, ADLs, and global supervision at rehabilitation discharge. Patients with bilateral cortical contusions require more global supervision at rehabilitation discharge but no more supervision for ambulation and ADLs. These findings may aid health care professionals and potential caregivers in planning for rehabilitation and supervision needs after rehabilitation discharge and, to a lesser extent, at 1 year after TBI.

Keyser-Marcus LA, Bricout JC, Wehman P, Campbell LR, Cifu DX, Englander J, High W, Zafonte RD. Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up. Arch Phys Med Rehabil 2002;83:635-41. Objective: To investigate the relation between selected acute injury and patient characteristics and subsequent return to work 1 to 5 years postinjury. Design: Longitudinal design with prospectively collected data. Data were collected on patients at the time of injury and each year postinjury for up to 5 years. Setting: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. Participants: Patients were selected from a national database of 538 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury (TBI) and seen at 1 to 5 years follow-up. Interventions: Not applicable. Main Outcome Measures: Employment status (employed vs not employed) at 1 to 5 years postinjury. Logistic regression analyses were performed to determine the extent to which selected variables predicted employment status at years 1 to 5 postinjury. Results: At year 1 postinjury, preinjury productivity, age, education, and rehabilitation length of stay were all significantly associated with postinjury employment. Preinjury employment and productivity and age significantly predicted employment at postinjury year 2. At year 3 postinjury, preinjury productivity, age, and FIM™ instrument discharge score significantly predicted employment status. Age was significantly associated with employment status at year 4 postinjury. Preinjury employment and productivity and Disability Rating Scale discharge score were found to be significant predictors of postinjury employment at year 5 follow-up. Conclusions: The relationship between certain acute injury and patient variables (eg, age, preinjury productivity, education, discharge FIM) and subsequent return to work may provide rehabilitation professionals with useful information regarding the intensity and types of services needed for individuals in the vocational rehabilitation planning process. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

This investigation evaluated yearly trends in charges and lengths of stay for patients with brain injury in acute care and rehabilitation settings over a 7 year period. Data was collected from 800 consecutive patients enrolled in four NIDRR Model Systems Traumatic Brain Injury programmes. Acute care daily charges showed almost routine increases, averaging nearly $550 per year. Conversely, lengths of stay generally showed a downward trend, with annual reductions averaging 2.25 days. Admission lengths of stay averaged 22-29 days between 1990-1994. Admissions averaged less than 20 days beginning in 1995, with the 1996 average of 16 days, nearly half that of the 1993 average. Between 1990-1996, average daily rehabilitation charges increased each year, with the rise averaging $83 or 7%. The rise in daily rehabilitation charges was offset by corresponding decreases in lengths of stay averaging 3.65 days or 8% annually. Increases in daily charges for brain injury rehabilitation care were roughly comparable to those for general medical care prices. However, the rate of change in acute care charges was substantially greater, with annual increases averaging 10% more than national medical care prices. The steady downward trend in lengths of stay raises serious concerns about the future availability of health care services to persons with brain injury.

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 χ 2 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 χ 2 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.

Residual emotional and behavioral difficulties in individuals who have sustained a traumatic brain injury (TBI) have been well documented in the literature. The issues are complex, interdependent, and often include substance abuse, depression, anxiety, chronic suicidal or homicidal ideation, poor impulse control, and significant degrees of frustration and anger. Often, preexisting psychological conditions and poor coping strategies are exacerbated by the trauma. Emotional and behavioral difficulties can interfere with the neurorehabilitation process at all levels. In acute rehabilitation, these issues have traditionally been addressed on an individual basis. However, in postacute settings, an interpersonal group format can be effectively implemented. The majority of individuals with TBI have minimal funding for long-term cognitive and behavioral remediation; often the only avenue available is support groups. This article will describe group psychotherapy models used with individuals with acute or postacute TBI within a comprehensive rehabilitation center. Interdisciplinary treatment of frustration and substance abuse and a continuum of care will be emphasized. Education, social support, skills development, interpersonal process, and cognitive-behavioral approaches will also be discussed. The psychotherapy groups focus on treatment of substance abuse and frustration management through education, social support, and development of interpersonal skills. Practical considerations of running such groups are presented.

Helicobacter pylori infection has been associated with acute and chronic gastritis, peptic ulcer disease, hypertension, and possibly gastric carcinoma and coronary artery disease. The prevalence of H pylori infection is more than 50% in people older than 60 years; however, the prevalence is not known in patients with traumatic brain injury (TBI) or cerebrovascular accidents who are treated in inpatient rehabilitation services. This report describes 10 symptomatic patients with TBI and strokes who were diagnosed with and treated for H pylori infection after transfer to a neurorehabilitation unit during a 12-month period. Physicians who treat patients with TBI and stroke need to be aware of the possible high prevalence of H pylori infection in their patients. The authors recommend H pylori screening for symptomatic patients in neurorehabilitation units and providing definitive treatment to prevent recurrent gastrointestinal bleeding, peptic ulcer disease, and gastritis.

Objective: To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients. Design: Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results. Setting: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. Participants: Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up. Main Outcome Measure: Return to work at 1-year follow-up. Results: Persons employed at l-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts. Conclusions: Persons obtaining better scores on certain acute measures (eg, Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patient's ability to return to work, as well as an operational definition for successful employment.

A review of the literature suggests that psychosocial disability in traumatic brain-injured (TBI) individuals and distress in families continues long after the initial injury. In this study the relationship of family stress to a number of factors was studied longitudinally. Caregivers of 51 TBI inpatients were interviewed at rehabilitation admission and by phone at 6, 12, and 24 months postinjury. Caregivers' most common complaints about their relatives were a lack of involvement in leisure activities, fatigue, slowness, and forgetfulness. Increasingly severe temper outbursts, anxiety, and self-centeredness were reported over time. Aggressiveness was reported by caregivers as moderate or severe in 31% of cases by 2 years postinjury. Of all complaints, only reports of inappropriate social behavior decreased over time. Despite caregivers' increasing complaints about their relatives, there were no trends toward greater self-reported stress over time. At the 2-year assessment, stress was significantly higher for caregivers of those with an at risk psychosocial history, and for those without sufficient funds for services. Caregivers reporting financial strain increased 22% from rehabilitation admission. Forty-seven percent of caregivers had altered or given up their jobs at 1 year postinjury, and 33% at 2 years postinjury. Although self-perceived measurements of stress did not increase over time, caregivers reported notable increases in medication use and substance use, and decreases in employment and financial status over the 2-year time period. When spouse and parent caregiver responses were compared, spouses reported a consistently greater number of behavioral problems, which increased in severity over time. Those behaviors associated with mood disturbances predominated.(ABSTRACT TRUNCATED AT 250 WORDS)