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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.

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.

OBJECTIVE: Study functional changes between one and five years after traumatic brain injury (TBI). DESIGN: Prospective cohort. SETTING AND PARTICIPANTS: TBI Model Systems National Database subjects using cohort with complete one and five year data (n = 301). MAIN OUTCOME MEASURES: Disability Rating Scale (DRS) Level of Functioning and Employability Items. RESULTS: On Level of Functioning, 53 (18%) individuals improved, 228 (76%) stayed the same, and 20 (7%) worsened by more than one point from Year 1 to Year 5. On Employability, 50 (17%) individuals improved, 237 (79%) stayed the same, and 14 (5%) worsened by greater than one point. Level of Functioning improvement was predicted by FIM-Motor, FIM-Cognitive, Rey Auditory Verbal Learning Test, Symbol Digit Modalities Test (written and oral), and Wechsler Adult Intelligence Scale-Revised Block Design, and worsening predicted by Symbol Digit Modalities Test (written and oral). Improvement in Employability was predicted by race, while Glasgow Coma Scale Eye Opening was predictive of worsening. CONCLUSIONS: Although the majority did not demonstrate meaningful change on the DRS items from year 1 to 5, some individuals made dramatic gains and a minority declined. There are demographic and functional indicators present at one-year post-injury that may be predictive of subsequent change. Language: en

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

Seel RT, Kreutzer JS, Rosenthal M, Hammond FM, Corrigan JD, Black K. Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation. Arch Phys Med Rehabil 2003;84:177-84. Objective: To identify the frequency and manifestations of depression after traumatic brain injury (TBI) and the factors that contribute to developing this mood disorder. Design: A prospective, nationwide, multicenter study; 17 centers supplied data from medical records and patient responses on a standardized criterion instrument. Setting: Traumatic Brain Injury Model Systems programs. Participants: A demographically diverse sample of 666 outpatients with TBI was evaluated 10 to 126 months after injury. Interventions: Not applicable. Main Outcome Measures: Depressive symptoms were characterized with the Neurobehavioral Functioning Inventory by using the Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) diagnostic framework. Analysis of variance and Pearson correlations were used to identify factors that were significantly related to depression. Results: Fatigue (29%), distractibility (28%), anger or irritability (28%), and rumination (25%) were the most commonly cited depressive symptoms in the sample. Twenty-seven percent of patients with TBI met the prerequisite number ([ge ]5) of criterion A symptoms for a DSM-IV diagnosis of major depressive disorder. Feeling hopeless, feeling worthless, and difficulty enjoying activities were the 3 symptoms that most differentiated depressed from nondepressed patients. Patients who were unemployed at the time of injury and who were impoverished were significantly more likely to report DSM-IV criterion A symptoms than patients who were employed, were students, or were retired due to age. Time after injury, injury severity, and postinjury marital status were not significantly related to depression. Conclusions: Patients with TBI are at great risk for developing depressive symptoms. Findings provide empirical support for the inclusion of depression evaluation and treatment protocols in brain injury programs. Unemployment and poverty may be substantial risk factors for the development of depressive symptoms. Future research should develop biopsychosocial predictive models to identify high-risk patients and examine the efficacy of treatment interventions. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Hanks RA, Wood DL, Millis S, Harrison-Felix C, Pierce CA, Rosenthal M, Bushnik T, High WM Jr, Kreutzer J. Violent traumatic brain injury: occurrence, patient characteristics, and risk factors from the Traumatic Brain Injury Model Systems project. Arch Phys Med Rehabil 2003;84:249-54. Objectives: To examine the occurrence of and characteristics associated with violent traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems (TBIMS) project for 4 of the 5 original Model Systems centers and to determine the patient characteristics of this group, as well as the risk factors for sustaining such an injury. Design: Prospective evaluation of individuals with violent TBI over a 10-year period. Setting: Four TBIMS centers. Participants: A total of 1229 individuals who received acute hospitalization and inpatient rehabilitation care for TBI. Interventions: Not applicable. Main Outcome Measure: The occurrence of a violent TBI. Results: Twenty-six percent of the participants in the TBIMS project sustained a violent TBI. This type of injury was more common in African-American men who were single and slightly older than the average TBI patient, were unemployed before injury, and had had a previous TBI. A higher injury rate was noted in the earlier part of the evaluation period. Those who sustained a violent TBI had higher levels of caregiver burden and disability, as well as decreased productivity and community reintegration at rehabilitation discharge and at 1 and 2 years postinjury. Conclusions: The occurrence of violent TBI in the TBIMS project is consistent with national trends of decreasing incidence of violent injuries in the 1990s. These results present a profile of those who have been injured through violence. The relative risks for sustaining such an injury appear to be well defined when considering demographic and temporal factors. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective: To survey individuals with acquired brain injury to assess multiple facets of interest, access, and familiarity necessary to implement new telerehabilitation technologies. Design: Anonymous mail survey. Setting: Community. Participants: Seventy-one respondents to a survey. These individuals had experienced acquired brain injury (predominantly severe traumatic brain injury [TBI]) and were living in the community. Surveys were mailed by a state chapter of the Brain Injury Association to a random selection of members with acquired brain injury. Main Outcome Measure: Survey designed specifically for this investigation. Results: The survey responses indicate that there is great interest in the possibility of accessing telerehabilitative services among individuals with acquired brain injury. In particular, there was strong interest expressed in services that could be used to assist with problems in memory, attention, problem-solving, and activities of daily living. Conclusions: Telemedicine, and more specifically telerehabilitation, holds great promise as an adjunct to traditional clinical service delivery. Little research in this area has been applied, however, to individuals with acquired brain injuries. Although on the surface, telerehabilitation seems to be an appropriate assessment and treatment modality for individuals with brain injury, it will only succeed if those individuals have the interest-and the access-necessary to use new and evolving technologies.

Boake C, Millis SR, High WM Jr, Delmonico RL, Kreutzer JS, Rosenthal M, Sherer M, Ivanhoe CB. Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury. Arch Phys Med Rehabil 2001;82:761-8. Objective: To evaluate whether early neuropsychologic testing is useful in predicting long-term productivity outcome after traumatic brain injury (TBI). Design: Validation cohort prediction study. Setting: Four inpatient brain injury rehabilitation programs participating in the Traumatic Brain Injury Model Systems project. Participants: A total of 293 adults with nonpenetrating TBI. Main Outcome Measures: Fifteen neuropsychologic tests were administered to patients who emerged from posttraumatic amnesia before rehabilitation discharge. Test scores were classified in the normal range or impaired range, using objective criteria. Outcome was defined as productive if the patient was competitively employed or enrolled full time in regular education. Results: Productivity at follow-up was predicted by completion of at least 1 neuropsychologic test before discharge, by an injury-test interval of less than 2 months, and by normal range scores on 10 of the 15 neuropsychologic tests. Normal range scores on these tests increased the probability of a productive outcome by 40% to 130%. Conclusions: Neuropsychologic testing can help predict long-term productivity even when performed before discharge from inpatient rehabilitation and at variable injury-test intervals. Early testing should be interpreted in relation to injury-test interval. Because tests of multiple neuropsychologic domains predicted outcome, comprehensive evaluations might be more useful in predicting outcome.

Occupational entry is an important issue for persons with disabilities, as many become or remain unemployed after their injury. After traumatic brain injury (TBI), individuals exhibit high unemployment rates, especially those persons with injuries of greater severity, a limited premorbid work history and/or persons from economically disadvantaged backgrounds. Vocational rehabilitation programs have been developed to improve employability. Traditional vocatio­ nal rehabilnation approaches, based on integrating work skills with cognitive rehabilitation models have proven only minimally effective with TBI. The supported employment model has been demonstrated to be much more effective with this group, as has an approach that combines vocational and psychosocial skills training along with job support. Even with these generally successful approaches, the literature on vocational rehabilitation in clients from economi­ cally disadvantaged environments who are diagnosed with TBI is limited. An approach for the economically disadvantaged, which combines work skills training in a real work community along with supported employment is presented. © 1998 Elsevier Science Ireland Ltd.

The ability of neuropsychological tests to predict later psychosocial outcome on the Community Integration Questionnaire (CIQ; WiIler, Rosenthal, Kreutzer, Gordon, & Rempel, 1993) was examined. A previous investigation by Millis, Rosenthal, and Lourie (1994) found that the Trail Making Test (TMT; Lezak, 1995) and the Rey Auditory Verbal Learning Test (RAVLT; Lezak, 1995) were related to performance on the CIQ at 1 year postinjury. The RAVLT and the TMT Parts A and B (TMT-A, TMT-B) in conjunction with age at time of injury significantly predicted psychosocial outcome as measured by individual self-report. When self-reported functioning was examined by domain, these variables significantly predicted home and social adaptation. These variables were applied to significant others' reports of community integration, where age and the TMT remained significant predictors of psychosocial outcome. These results underscore the utility of neuropsychological measures in the prediction of later community integration after traumatic brain injury.

Objective:To examine the relationship between the Neurobehavioral Cognitive Status Examination (Cognistat) and established neuropsychological measures of related constructs in a traumatic brain injury (TBI) sample.Design:A retrospective study of 45 patients who were administered Cognistat as part of

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

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

Objectives:To characterize changes in employment status and community integration following traumatic brain injury and to investigate relationships among outcome, sociodemographic, and injury-related variables.Design:Longitudinal analyses of employment (n=42) and community Integration (n=53) were co

The evaluation of competency in an individual with acquired brain injury has become an area of increasing concern to health care professionals in recent years. The evolving neurobehavioral status, nature and extent of diminished cognition and the post-discharge environment are factors which must be considered when assessing the competency of a person with brain injury to function independently in the community. In addition, clinicians must be familiar with the distinctions between various definitions and models of competency. In most rehabilitation settings, competency to consent to treatment, care for self and property and manage financial affairs are the issues most commonly observed. In the case of acquired brain injury, clinicians are well-advised to maximize a patient's autonomy and avoid a paternalistic stance, whenever possible. Treatment of the patient and family should be directed toward developing compensatory behaviours to allow for safe and successful community reintegration with as much dignity and autonomy as possible.

Outcome of 295 rehabilitation patients with mild, moderate, and severe brain injury was investigated prospectively at five regional medical centers using the Neurobehavioral Rating Scale. Mean factor scale scores were generally low. with the cognition mean highest and the excitement mean lowest. Regardless of scale, the most significant neurobehavioral difficulties were related to memory, insight, attention, alertness, fatigue, and blunted affect. Conversely, problems rated as least severe included hallucinations, guilt, excitement and lability of mood. Approxi­ mately 9% of the sample had at least a moderate problem with agitation, an item on the excitement scale. The general pattern of mean factor scale elevations was consistent with other studies. No relationship was found between injury severity and neurobehavioral characteristics. The relatively low incidence of neurobehavioral problems may reflect recovery and effective interdisciplinary management.

In November 2001, a conference convened to discuss the state of the science of measuring of quality of life (QOL) in rehabilitation medicine. The meeting brought together leading researchers in areas of behavioral health and physical medicine and rehabilitation to address the fragmentation that exists across specialty areas and disciplines. The goal was to bridge terminology, techniques, and advances across the fields of behavioral and rehabilitation medicine. The 5 topic areas included: (1) general versus targeted measurement, (2) QOL in policy development, (3) measuring QOL from the patient's perspective, (4) cultural aspects of QOL measurement, and (5) the future of QOL research. This introduction synthesizes the information presented at the conference and provides context to the articles contained in this 2-part supplement.

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

Community integration is defined as integration into a home-like setting, integration into a social network, and integration into productive activities such as employment, school, or volunteer work. For the purpose of evaluating outcomes for individuals with traumatic brain injury (TBI) who are prov

The relationship of medical variables and discharge functional status to vocational and educational outcomes was examined in 79 closed head-injured patients who were consecutively admitted to an inpatient rehabilitation hospital during a two-year period. A follow-up study, conducted after hospital discharge (median, 16.5 months), found that 66% (n = 52) of the patients had returned to work or school, while 34% (n = 27) did not. Patients were divided into return and non-return to work groups. Traditional variables included age, severity of brain-damage as characterized by CT head scan, duration of post-traumatic amnesia, duration of coma, length of stay and acute inpatient rehabilitation program. Discharge functional scores were analysed by t-tests and chi-square analysis. Results suggest that traditional factors of younger age, shorter length of coma, minimal CT head scan findings and shorter length of stay were significant contributors to educational/vocational outcome. Their significance was enhanced by discharge functional profile measurement of medical, physical and psychological/neuropsychological integrity. Those functional measures not significant were in social, vocational, recreational and communication areas. These factors may continue to improve over a longer period of time and should be tracked in the post-acute rehabilitation phase for their significance in return to work/school.

(1) to determine differences between minorities vs. non-minorities on demographic, injury and rehabilitation characteristics and functional outcomes at admission, discharge and 1-year post-injury and (2) to examine differences in functional outcome at 1-year post-injury among (African-Americans, Hispanics and Whites).Retrospective study.Longitudinal data were extracted from the TBI Model Systems database.4929 individuals with moderate-to-severe TBI (3354 Whites vs. 1575 Minorities: 1207 African-Americans and 368 Hispanics) hospitalized between 1989-2004.Functional outcomes at 1-year post-injury (Disability Rating Scale, Functional Independence Measure, Glasgow Outcome Scale-Extended and Community Integration Questionnaire).At discharge and 1-year post-injury, minorities had poorer functional outcomes compared with Caucasians on all measures. After controlling for sociodemographic, injury and functional characteristics at admission, Hispanics and African-Americans still showed worse functional outcomes at 1-year post-injury compared with Whites on the DRS, FIM and CIQ. There were no significant differences between African Americans and Hispanics.Minorities had significantly reduced long-term functional outcome after rehabilitation relative to Whites. It is imperative that rehabilitation professionals' consider factors related to poorer long-term functional outcome and work to improve the quality of life of minorities with TBI.

Corrigan JD, Selassie AW, Lineberry LA, Millis SR, Wood KD, Pickelsimer EE, Rosenthal M. Comparison of the Traumatic Brain Injury (TBI) Model Systems national dataset to a population-based cohort of TBI hospitalizations. Objective To determine whether severity alone accounts for differences observed between a population-based cohort of acute care hospitalizations for traumatic brain injury (TBI) and the Traumatic Brain Injury Model Systems (TBIMS) national dataset. Design Prospective cohort. Setting Acute care hospitals in South Carolina and TBIMS rehabilitation centers. Participants Subjects enrolled in the TBIMS national dataset and the South Carolina TBI Follow-up Registry (SCTBIFR). Interventions Not applicable. Main Outcome Measures Comparable variables in the 2 datasets included demographic characteristics, etiology of injury, initial Glasgow Coma Scale score, Abbreviated Injury Scale score for the head region derived from International Classification of Diseases codes, presence of computed tomography (CT) abnormalities, acute hospital length of stay, and payer source. Results As hypothesized, TBIMS participants showed greater initial injury severity, frequency of abnormal CT scans, and longer lengths of acute care hospitalization, explaining over 75% of cohort membership. Counter to a priori hypotheses, when all other factors were held constant, there were also differences in racial and ethnic background and insurance payer source. Conclusions Differences between the TBIMS cohort and patients acutely hospitalized with TBI are primarily due to injury severity; however, an additional difference in payer source may need to be taken into account when generalizing findings. Results showed that TBIMS and SCTBIFR datasets are complementary, each having different strengths for understanding factors that impact long-term recovery after TBI. Recommendations are made for methodologic improvements in both data collection for the TBIMS and future outcome surveillance.

Arango-Lasprilla JC, Rosenthal M, DeLuca J, Cifu DX, Hanks R, Komaroff E. Functional outcomes from inpatient rehabilitation after traumatic brain injury: how do Hispanics fare? Objective To examine the relation between Hispanic ethnicity and rehabilitation outcome in traumatic brain injury (TBI) survivors. Design Retrospective study. Setting Longitudinal dataset of the Traumatic Brain Injury Model Systems national database. Participants Persons (N=3056; 2745 whites vs 311 Hispanics) with moderate to severe TBI hospitalized between 1989 and 2003. Interventions Not applicable. Main Outcome Measures Functional outcomes at discharge and 1-year follow-up (Disability Rating Scale [DRS], FIM instrument). Glasgow Outcome Scale−Extended (GOS-E), and the Community Integration Questionnaire (CIQ) were measured at follow-up only. Results At admission, Hispanics were less educated ( P ≤.001), earned less money ( P ≤.05), and were younger ( P ≤.001) than whites. Hispanics had lower GOS-E scores ( P ≤.01) at acute hospital admission compared with whites. Despite similar functional status at inpatient rehabilitation discharge, Hispanic ethnicity was associated with poorer functional outcomes at 1 year postinjury (DRS, FIM, CIQ), after controlling for age, length of posttraumatic amnesia, injury severity, DRS score at admission, FIM score at admission, and preinjury educational level ( P Conclusions Hispanics showed significantly reduced long-term functional outcome after rehabilitation relative to whites. Rehabilitation professionals should recognize the possible impact of individual differences and diverse sociodemographic, injury, and rehabilitation characteristics so that differential health outcomes among TBI survivors can be reduced or eliminated.

DeLisa JA, Rosenthal M: Funding for rehabilitation medicine: Building research capacity. Am J Phys Med Rehabil 2005;84:991–998.

Study functional changes between one and five years after traumatic brain injury (TBI).Prospective cohort.TBI Model Systems National Database subjects using cohort with complete one and five year data (n = 301).Disability Rating Scale (DRS) Level of Functioning and Employability Items.On Level of Functioning, 53 (18%) individuals improved, 228 (76%) stayed the same, and 20 (7%) worsened by more than one point from Year 1 to Year 5. On Employability, 50 (17%) individuals improved, 237 (79%) stayed the same, and 14 (5%) worsened by greater than one point. Level of Functioning improvement was predicted by FIM-Motor, FIM-Cognitive, Rey Auditory Verbal Learning Test, Symbol Digit Modalities Test (written and oral), and Wechsler Adult Intelligence Scale-Revised Block Design, and worsening predicted by Symbol Digit Modalities Test (written and oral). Improvement in Employability was predicted by race, while Glasgow Coma Scale Eye Opening was predictive of worsening.Although the majority did not demonstrate meaningful change on the DRS items from year 1 to 5, some individuals made dramatic gains and a minority declined. There are demographic and functional indicators present at one-year post-injury that may be predictive of subsequent change.

To investigate the relationship of demographic characteristics of the caregiver (i.e. race, age, household income, education) to caregiver burden, family needs, family functioning and social support to assess the predictors of caregiver burden.Information was obtained through mailed surveys and follow-up phone interviews.Participants were 24 African American and 21 White caregivers of individuals with traumatic brain injury who were at least 1-year post-injury. Measures administered included the Head Injury Family Interview, Family Needs Questionnaire, Family Assessment Device and the NON, a measure of social support.Regression analyses revealed that importance of needs and percentage of needs met accounted for a significant amount of the variance in predicting affective/behavioural, cognitive and physical/dependency burden.Rehabilitation professionals need to provide support that includes ongoing assessment of needs and provides a resource for steering caregivers to potential sources for meeting those needs.

Sherer M, Sander AM, Nick TG, High WM Jr, Malec JF, Rosenthal M. Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI Model Systems. Arch Phys Med Rehabil 2002;83:183-92. Objective: To evaluate the contribution of early cognitive assessment to the prediction of productivity outcome after traumatic brain injury (TBI) adjusted for severity of injury, demographic factors, and preinjury employment status. Design: Inception cohort. Setting: Six inpatient brain injury rehabilitation programs. Participants: A total of 388 adults with TBI whose posttraumatic amnesia (PTA) resolved before discharge from inpatient rehabilitation. Interventions: Administered neuropsychologic tests during inpatient stay on emergence from PTA. Follow-up interview and evaluation. Predictor measures also determined. Main Outcome Measure: Productivity status at follow-up 12 months postinjury. Results: Multiple logistic regression analysis revealed that preinjury productivity status, duration of PTA, education level, and early cognitive status each made significant, independent contributions to the prediction of productivity status at follow-up. When adjusted for all other predictors, persons scoring at the 75th percentile on early cognitive status (less impaired) had 1.61 times greater odds (95% confidence interval [CI], 1.07-2.41) of being productive follow-up than those scoring at the 25th percentile (more impaired). Without adjustment, persons scoring at the 75th percentile had 2.46 times greater odds (95% CI, 1.77-3.43) of being productive at follow-up. Conclusions: Findings support the utility of early cognitive assessment by using neuropsychologic tests. In addition to other benefits, early cognitive assessment makes an independent contribution to prediction of late outcome. Findings support the clinical practice of performing initial neuropsychologic evaluations after resolution of PTA. © 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.

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

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

Rosenthal M. American Congress of Rehabilitation Medicine in 2006: embracing the future. The American Congress of Rehabilitation Medicine (ACRM) modified its mission and structure in 1997 to become an organization focused on medical rehabilitation research. Initially, this transformation accelerated an already diminishing membership, a weakened financial condition, and some level of dysfunction within the organizational structure. In recent years, with the advent of evidence-based practice and the expectation that empirical research is critical to the survival of clinical specialties such as rehabilitation medicine, ACRM has become re-energized. New initiatives have been spawned that have led to stabilization and an influx of new members, a measurable improvement in the quality of scientific presentations at, and participation in, the annual meetings, efforts directed toward increasing the visibility and involvement of ACRM on an international level, programming directed toward early career scientists, strong public policy advocacy, and renewed and expanded inter-organizational partnerships. In addition, the financial position of ACRM has improved markedly and prospects toward long-term fiscal health and growth are “the new reality.” ACRM has now moved significantly beyond the “survival” step of the Maslow hierarchy toward the goal of self-actualization.

Persons entering or returning to the workforce after brain injury often require assistance to identify, locate, secure and maintain employment. This is especially true for workers from economically disadvantaged environments who may have limited pre-injury work experience. Supported employment, the use of natural supports, and community-based approaches are helpful for the process of identifying, securing and maintaining work. However, reports are limited as to how these approaches are helpful for economically disadvantaged persons, especially in identifying meaningful work. An approach is described here which combines work adjustment training and supported employment; which is helpful in identifying consumer interest, and in improving position attainment, job retention and work satisfaction. A sample of persons (n = 38) with brain injury were contacted after completing the programme. A total of 59% of these persons remained employed at follow-up, compared to 32% at time of injury. Additional outcome data are presented to describe the usefulness of this approach.

Objective: Review the existing literature on the incidence, neurobiological and psychosocial correlates, and methods of assessment and treatment of depression following traumatic brain injury (TBI). Data Sources: Computerized database searches of the English-language literature from Index Medicus, Psychological Abstracts, Excerpta Medica, and Cumulative Index of Nursing and Allied Health Literature. Study Selection: Given the relatively small number of publications specifically related to TBI and depression, all studies appearing in the peer-reviewed literature were included in the review. In addition, studies examining depression and other neurologic diseases (eg, stroke) were also reviewed as to the potential applicability of the theoretical model or methodology used. Conclusions: Depression occurs with sufficient frequency to be considered a significant consequence after TBI. Depression can impede the achievement of optimal functional outcome, whether in the acute or chronic stages of recovery. It appears that a combination of neuroanatomic, neurochemical, and psychosocial factors is responsible for the onset and maintenance of depression. Its treatment is typically psychopharmacologic, with best results obtained from nontricyclic antidepressants. These results have not been confirmed in double-blind clinical trials, however. Future research should use comprehensive, integrative models of depression that include demographic, biologic, and psychosocial factors; enhanced functional neuroimaging techniques; controlled studies of psychopharmacologic and other interventions; and prospective designs with long-term follow-up.

The articles in the current supplement (Part II) present emerging issues in the measurement of quality of life (QOL). The articles were prepared based on presentations at a meeting held in November 2001. Part I (December 2002) provided important background information, definitions, and approaches that have been used in various rehabilitation populations. The articles in the current supplement are intended to provide information about new advances in QOL measurement. They review issues such as measuring QOL from the individual's perspective, adapting instruments for different cultures and illiteracy, and using advanced psychometric techniques to build a computer-adapted measurement system. Novel solutions are offered. We hope that this information can be used to set a research agenda for improving the measurement of QOL in rehabilitation medicine. The present article outlines these issues and provides a context for the information that has been presented in the 2 supplements.