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Background There are an estimated 11 million burn injuries requiring medical attention every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients’ utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors. Methods We conducted on March 18th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors’ utility scores via a standardized indirect instrument. Results We identified 15 studies that reported burn injury survivors’ utility scores. Most studies used the EQ-5D instruments to assess patients’ utility scores. Results varied substantially between studies, ranging from a low of 0.11 to a high of 0.94. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury. Conclusion Unfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients’ utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.

BACKGROUND: A number of physiological and atmospheric variables are believed to increase spasticity in persons with spinal cord injury (SCI) based on self-reported measures, however, there is limited objective evidence about the influence of these variables on spasticity. OBJECTIVE: We investigated the relationship between physiological/ atmospheric variables and level of spasticity in individuals with SCI. METHODS: In 53 participants with motor-incomplete SCI, we assessed the influence of age, time since injury, sex, injury severity, neurological level of injury, ability to walk, antispasmodic medication use, temperature, humidity, and barometric pressure on quadriceps spasticity. Spasticity was assessed using the pendulum test first swing excursion (FSE). To categorize participants based on spasticity severity, we performed cluster analysis. We used multivariate stepwise regression to determine variables associated with spasticity severity level. RESULTS: Three spasticity groups were identified based on spasticity severity level: low, moderate, and high. The regression analysis revealed that only walking ability and temperature were significantly related to spasticity severity. CONCLUSIONS: These outcomes validate the self-reported perception of people with SCI that low temperatures worsen spasticity. The findings refine prior evidence that people with motor-incomplete SCI have higher levels of spasticity, showing that those with sufficient motor function to walk have the highest levels of spasticity.

INTRODUCTION: Multi-ligamentous knee injuries (MLKI) are rare orthopedic injuries with diverse approaches to its management protocol. The purpose of this study was to determine the epidemiology of MLKI in our centre and its outcome in single stage reconstruction. METHODS: 60 patients who were surgically treated for MLKI between 2014 and 2018 were included in this study, data was collected pre and postoperatively and their Lysholm and IKDC scores were used to evaluate the outcomes. RESULTS: A male predominance was noted in the present study. Road traffic accidents (RTA) were the most common mode of injury (66.7%). ACL & MCL combination constituted the most common injury pattern (36.7%). 41.7% of our patients were treated within 3 weeks from injury and 58.3% were treated 3 weeks after injury and there was no statistically significant difference in their outcomes with a p value > 0.05 for their post op Lysholm scores and post op IKDC scores. Overall, there was a statistically significant difference in outcomes post surgery with regards to pre-operative and post-operative Lysholm and IKDC scores in our patients with a p value 3 weeks) surgery. Single stage surgical management of MLKI produce considerably better outcomes compared to staged management. It was also found that surgical management of MLKI with reconstruction could help patients to return to their pre operative level of sports activities with a proper rehabilitation protocol.

OBJECTIVE Fear avoidance behavior after a concussion or mild traumatic brain injury (mTBI) is associated with a number of adverse outcomes, such as higher symptom burden, emotional distress, and disability. The Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) is a recently developed and validated self-report measure of fear avoidance after mTBI. The objective of this study was to derive clinical normative data for the FAB-TBI. To determine whether demographic stratification was necessary and to further support clinical interpretation, we also explored associations between fear avoidance behavior and demographic and injury variables. SETTING Five concussion clinics in Canada. PARTICIPANTS Adults who sustained an mTBI (N = 563). DESIGN Cross-sectional. MAIN MEASURES Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) and measures of postconcussion symptom burden (Rivermead Postconcussion Symptoms Questionnaire, Sport Concussion Assessment Tool-5) at clinic intake. RESULTS Generalized linear modeling revealed that females reported more fear avoidance than males (95% CI = 0.66 to 2.75), indicating that FAB-TBI normative data should be stratified by sex. Differences between recruitment sites on FAB-TBI scores were reduced but not eliminated by controlling for potential confounds. Loss of consciousness (95% CI =0.61 to 2.76) and higher postconcussion symptom burden (95% CI = 0.79 to 1.03) were also associated with higher FAB-TBI scores, but time since injury was not (95% = CI -0.4 to 0.03). Tables to convert FAB-TBI raw scores to Rasch scores to percentiles are presented. CONCLUSION These findings support clinical interpretation of the FAB-TBI and further study of fear avoidance after mTBI.

Injury can produce long-lasting motivational changes that may alter decisions made under risk. Our objective was to determine whether a routine painful husbandry procedure, hot-iron disbudding, affects how calves trade off risk avoidance against a competing motivation (i.e., feeding), and whether this response depends on time since injury. We used a startle test to evaluate this trade-off in calves disbudded 0 or 21 days previously and non-injured control calves. For 3 days, calves were individually habituated to the testing arena in which they received a 0.5 L milk meal via a rubber teat. On the 4th day, upon approaching the milk reward, the calf was startled by a sudden noise. We assessed the duration and magnitude of the calf’s startle response, their latency to return to the milk bottle, and duration spent suckling after startling. No treatment differences were observed in the duration and magnitude of the startle response or in the probability of returning to the bottle after startling. However, among those who did return, disbudded calves spent longer suckling, indicating they accepted more risk in order to feed compared to controls. In addition, calves with 21-day-old injuries tended to return to the bottle faster compared to newly disbudded calves and controls. We suggest that hot-iron disbudding increases calves’ motivation to suckle, as they were more likely to prioritize this behaviour over risk avoidance compared to control calves. This effect was most evident 21 days after disbudding, indicating that injury can produce long-term changes in motivational state.

Supplemental Digital Content is available in the text, In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2) emerged in Wuhan City. The present study aimed to assess the demographic variables, causes, and patterns of maxillofacial injuries managed at a teaching hospital in Wuhan City during the transmission control measures in the coronavirus disease 2019 (COVID-19) epidemic. In this retrospective study, all patients treated for maxillofacial injuries in the hospital between January 23 and April 7 (2019 and 2020) were involved. Epidemiologic information, including the number of patients, gender, age, etiology, time since injury to the clinic visit, and type of maxillofacial injuries, was recorded. Data of the 2 periods (2019 and 2020) were compared and analyzed. A total of 337 patients had maxillofacial injuries at the 2-time intervals: 74 in 2020 and 263 in 2019. The characteristics of maxillofacial injuries had changes during the transmission control measures in the COVID-19 epidemic, which included the number of patients, gender, age, etiology, time since injury to the clinic visit, and type of maxillofacial injuries. The transmission control measures during the COVID-19 epidemic had a significant impact on the epidemiology of maxillofacial injuries in Wuhan City.

Objective: To examine the symptoms experienced and the change in driving habits in individuals with concussion.Materials and methods: A survey was created by a team of rehabilitation professionals who see persons with concussion in their clinics. The survey captured demographics, mechanism of injury, date of injury, symptoms experienced during driving, if drivers felt safe when driving, and changes in driving habits since the concussion. Non-parametric tests were used to compare symptoms experienced and driving habits across three groups which were created based on time since injury.Results: Of the 140 participants, 74% (104/140) had resumed driving after concussion; of these 27% (28/104) reported that they felt unsafe while driving. Forty-four per cent (46/104) experienced symptoms while driving, of which headache, and difficulty concentrating were the most common symptoms experienced throughout the concussion spectrum (acute to chronic phase). Most drivers (78/104, 75%) with concussion had changed their driving habits by driving less often and shorter distances, and by avoiding nighttime driving and heavy traffic areas.Conclusions: Headache and concentration problems were experienced by drivers regardless of the time since injury. Most drivers had made changes to their driving habits. Clinicians should consider the symptom burden patients experience and discuss driving restrictions to ensure driving safety.

Study design Longitudinal study. Objectives This study aimed to examine level and variations of life satisfaction (LS) across the seasons in persons with spinal cord injury (SCI). Setting Polish sample of persons with SCI. Methods The study included 56 persons with SCI, who repeatedly completed the Life Satisfaction Questionnaire (LiSaT-9), and a study-specific questionnaire across the four seasons in a calendar year. Mixed model analyses were performed to: (1) examine seasonal changes in LS; (2) explore the possible moderating factors on seasonal changes in LS. Results There were significant seasonal trends in overall and domain-specific LS scores; yet, these changes differed in terms of shape (i.e. linear vs. quadratic). In general, the highest LS scores occurred in spring across all domains, followed by a significant reduction in summer; yet, there were u-shape trends in LS domain scores for life as a whole, vocational, and financial situation and partner relations (P-for-quadratic trends ≤0.05). Five individual characteristics, i.e. place of living, education, gender, physical activity, and time since injury significantly moderated seasonal trends in LS scores (P's for interaction ≤ 0.05). Conclusion Life satisfaction in persons with SCI differs significantly in relation to different seasons throughout a year. The season of the year should be considered in future studies on LS and included in evaluating and projecting healthcare interventions or programs for persons with SCI.

Objective To characterize fatigue in children with moderate or severe traumatic brain injury (TBI) and to identify associated factors. Setting Urban tertiary pediatric healthcare facility. Participants Children aged 5 to 15 years with a moderate TBI (n = 21), severe TBI (n = 23), or an orthopedic injury (OI; n = 38). Design Case-control study. Main measures (i) Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL-MFS), completed by parents and children; (ii) Sleep Disturbance Scale for Children, completed by parents. Data on injury-specific factors and other factors of interest were also collected. Results The 2 TBI groups did not differ on any of the fatigue outcomes (child or parent ratings). Relative to the OI group, parents rated children in both TBI groups as experiencing greater fatigue. However, on self-ratings, only children with moderate TBI endorsed greater fatigue. Sleep was commonly associated with fatigue, with child sleep disturbance and child sleep hygiene associated with parent-rated and self-rated child fatigue, respectively. Individually, there were no cases of "normal" fatigue coinciding with severe sleep disturbance. However, there were several cases of severe fatigue coinciding with normal sleep. Additional factors associated with fatigue were older age at injury, longer time since injury, and/or greater internalizing difficulties. Conclusion Children with moderate and severe TBI experience greater fatigue than OI controls. Parent and child ratings of fatigue appear to be associated with different factors, indicating that fatigue management may require a broad range of treatments.

OBJECTIVES To evaluate change in mobility independence (MI) in community dwelling persons with spinal cord injury (SCI). PARTICIPANTS Community Survey. DESIGN Cohort study. Rasch analysis was applied to the mobility subscale of the Spinal Cord Independence Measure - Self-Report data from years 2012 to 2017, resulting in a Rasch Mobility Independence Score (RMIS). We employed multilevel modeling to examine RMIS and its change over 5 years, adjusting for demographics and SCI severity; random forest regression was applied to determine the impact of modifiable factors (e.g. environmental factors, home-support) on its change. RESULTS The analysis included 728 participants. The majority (≈85%) of participants demonstrated little or no change in RMIS from 2012 to 2017; however, a smaller proportion (15%) showed considerably large change of more than 10 on the 100-point scale. A mixed-effects model with random slopes and intercepts described the dataset very well (conditional R2 of 0.95) in terms of demographics and SCI severity. Age was the main predictor of change in RMIS. Considering SCI severity, change in RMIS was related to age for the subgroup with paraplegia, and to time since injury for the subgroup with tetraplegia. No impact of modifiable factors was found. CONCLUSION RMIS in persons with SCI changes over a period of 5 years, especially in elder patients with paraplegia and persons with incomplete tetraplegia with more than 15 years of time since injury. During routine follow-up change in mobility independence should be assessed in order to timely intervene and prevent mobility loss and participation limitations.

Traumatic Brain Injury (TBI) associated cognitive impairments may pose an obstacle to homework engagement in Cognitive Behavior Therapy (CBT) for depression and anxiety. The current study examined the association of demographic, injury-related and CBT process variables with homework engagement in CBT adapted for TBI -related cognitive impairments (CBT-ABI). The audio-recordings of 177 CBT-ABI sessions, representing 31 therapist-client dyads, were assessed from the independent observer perspective. Client homework engagement, therapist competence in assigning and reviewing homework, and working alliance strength, were measured. Multi-level mixed model regressions showed that older client age, more time since injury, stronger working alliance and greater therapist competence in homework review, were significantly associated with higher levels of homework engagement. The findings highlight how CBT-ABI therapists can possibly enhance homework engagement for clients with TBI.

Traumatic brain injury (TBI) patients present on a spectrum from hypocoagulability to hypercoagulability, depending on the injury complexity, severity, and time since injury. Prior studies have found a unique coagulopathy associated with TBI using conventional coagulation assays such as INR; however, few studies have assessed the association of TBI and coagulopathy using viscoelastic assays that comprehensively evaluate the coagulation in whole blood. This study aims to reevaluate the TBI-specific trauma-induced coagulopathy using arrival thrombelastography. Because brain tissue is high in key procoagulant molecules, we hypothesize that isolated TBI is associated with procoagulant and hypofibrinolytic profiles compared with injuries of the torso, extremities, and polytrauma, including TBI.Data are from the prospective Trauma Activation Protocol study. Activated clotting time (ACT), angle, maximum amplitude (MA), 30-minute percent lysis after MA (LY30), and functional fibrinogen levels (FFLEV) were recorded. Patients were categorized into isolated severe TBI (I-TBI), severe TBI with torso and extremity injuries (TBI + TORSO/EXTREMITIES), and isolated torso and extremity injuries (I-TORSO/EXTREMITIES). Poisson regression was used to adjust for multiple confounders.Overall, 572 patients (48 I-TBI, 45 TBI + TORSO/EXTREMITIES, 479 I-TORSO/EXTREMITIES) were included in this analysis. The groups differed in INR, ACT, angle, MA, and FFLEV but not in 30-minute percent lysis. When compared with I-Torso/Extremities, after adjustment for confounders, severe I-TBI was independently associated with ACT less than 128 seconds (relative risk [RR], 1.5; 95% confidence interval [CI], 1.1-2.2), angle less than 65 degrees (RR, 2.2; 95% CI, 1.4-3.6), FFLEV less than 356 (RR, 1.7; 95% CI, 1.2-2.4) but not MA less than 55 mm, hyperfibrinolysis, fibrinolysis shutdown, or partial thromboplastin time (PTT) greater than 30.Severe I-TBI was independently associated with a distinct coagulopathy with delayed clot formation but did not appear to be associated with fibrinolysis abnormalities. Low fibrinogen and longer ACT values associated with I-TBI suggest that early coagulation factor replacement may be indicated in I-TBI patients over empiric antifibrinolytic therapy. Mechanisms triggering coagulopathy in TBI are unique and warrant further investigation.Retrospective cohort study, prognostic, level III.

ObjectiveTo characterize heart rate (HR) changes during autonomic dysreflexia (AD) in daily life for individuals with chronic spinal cord injury (SCI).DesignData analysis of two prospective clinical studies and one cross-sectional study.SettingSingle-center study.ParticipantsForty-five individuals (including 8 females) with a chronic SCI at or above the sixth thoracic spinal segment with confirmed AD, and a median age and time since injury of 43 years (interquartile range [IQR] 36 – 50) and 17 years (IQR 6 – 23) respectively, were included for analysis.InterventionsNot applicable.Main outcome measureAny systolic blood pressure (SBP) increase ≥ 20mmHg from baseline from a 24-hour ambulatory surveillance period was identified and categorized as either confirmed (i.e. known AD trigger), unknown (i.e. no diary entry), and unlikely (i.e. potential physical activity driven SBP increase). SBP-associated HR changes were categorized as either unchanged, increased or decreased compared to baseline.ResultsA total of 797 episodes of SBP increase above AD threshold were identified and classified as confirmed (n = 250, 31.4%), unknown (n = 472, 59.2%) or unlikely (n = 75, 9.4%). Median SBP changes and median SBP-related HR changes were 37 mmHg and -8 bpm, 28 mmHg and -6 bpm, or 30 mmHg and -4 bpm for confirmed, unknown, or unlikely episodes, respectively. HR-decrease/increase ratio was 3:1 for confirmed and unknown, and 1.5:1 for unlikely episodes. HR changes resulting in brady-/tachycardia were 34.4% / 2.8% for confirmed, 39.6% / 3.4% unknown, and 26.7% / 9.3% for unlikely episodes, respectively.ConclusionsOur findings suggest that the majority of confirmed AD episodes are associated with a HR decrease. Further improvements, such as more precise participant diaries combined with the use of 24-hour Holter electrocardiogram and wearable-sensors-derived measures of physical activity could provide a better, more detailed characterization of HR changes during episodes of AD.

Over the last decade, much research has been devoted to concussion among military personnel. Post-concussion symptoms after blast-related concussion are common, but it is unknown whether symptom reporting differs over time. This study's objective was to assess the relationship between time since injury and post-concussion symptom reporting. We conducted a retrospective review of existing records to identify service members who experienced blast-related concussion during deployment between 2007 and 2012 and who responded to a Post-Deployment Health Assessment (PDHA). The study population included 3690 military personnel grouped by time between injury and PDHA completion: 1-90 days (45.3%

We thank Dr. Kawada for his comments and inquiry on our article.1 Our report of plasma and exosomal axonal, inflammatory, and vascular biomarkers is part of a discovery project studying candidate biomarkers of remote mild TBI (mTBI) outcomes among service members and veterans with combat-related mTBI enrolled in the Chronic Effects of Neurotrauma Consortium longitudinal study. This study complemented our previous report that evaluated biomarkers associated with neurodegeneration tau, hyperphosphorylated tau, and beta amyloid-40 and beta amyloid-42.2 The samples in this analysis were obtained a mean of 8 years after the most severe combat-related mTBI. By contrast, the specimens in the earlier study by Gill et al.3 were obtained much earlier from service members who had sustained an mTBI within the previous 3 years. In addition to the difference in mean time since injury, there were other methodological differences between the studies. All results are preliminary and require validation in a larger cohort.

Study design Cross-sectional study. Objectives The purpose was to reveal late health consequences and life issues after a traumatic spinal cord injury (tSCI) in North Macedonia (NM). Setting Community dwelling adults with tSCI in NM. Methods Persons that sustained tSCI in 1999-2005 were selected, physical examined and a questionnaire was administered. Descriptive statistics were conducted. Results From 203 eligible persons, 40 agreed to participate. Mean (range) age at time of injury was 36 (27-75) years and time since injury ranged 9-20 years. Around seventy percent reported current health problems, of which pain and spasm (>60%) were most prevalent, followed by urinary tract infections and pressure injuries. About 30% had never been to a medical specialist and ≈70% had only once been to physiotherapy after discharge from the primary inpatient period. Only one participant had a fully adjusted home for a person with a disability. Those with most severe tSCI (American Spinal Injury Association Impairment Scale (AIS) A, B, and C) seldom left their homes. About 50% were retired and/or unemployed, 50% were working. Conclusion This is the first study describing community-dwelling persons with a tSCI in NM. Our study revealed that persons with tSCI reported health issues mostly related to pain, spasms, urinary tract infections and pressure injuries. They lacked follow-ups, experienced physical barriers and poor inclusion in the society, and lacked financial support. Therefore, they were often socially isolated and fully dependent on their families. NM is in need of structured rehabilitation programs and better adaption for persons with reduced mobility.

Background: Symptom reporting with scales such as the Post-Concussion Symptom Scale (PCSS) is one of the most sensitive markers of concussed status and/or recovery time, It is known that time from injury until initial clinic visit affects symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cutoff scores for the PCSS based on earlier versus later clinical presentation postconcussion. Purpose: To evaluate if time since injury after sports-related concussion (SRC) affects clinical cutoff scores for total PCSS and PCSS factors in differentiating athletes with SRC from healthy controls and predicting prolonged recovery (>30 days) after SRC. Study Design: Cohort study; Level of evidence, 3. Methods: A chart review was conducted of clinical data from patients with SRC (age, 13-25 years; n = 588; female, n = 299) who presented to concussion specialty clinics. Participants were categorized on the basis of time from injury: early (≤7 days; n = 348) and late (8-21 days; n = 240). Outcomes were total symptom severity (ie, total PCSS score) and total score for each of 4 symptom factors (cognitive/migraine/fatigue [CMF], affective, sleep, and somatic). Area under the curve (AUC) analyses were conducted using the Youden index to optimize sensitivity and specificity cutoffs. Results: In the early group, the CMF factor (cutoff, ≥7; AUC = 0.944), affective factor (cutoff, ≥1; AUC = 0.614), and total PCSS (cutoff, ≥7; AUC = 0.889) differentiated athletes with SRC from controls. In the late group, the CMF factor cutoff was reduced (cutoff, ≥4; AUC = 0.945), while the total PCSS score (cutoff, ≥7; AUC = 0.892), affective factor (cutoff, ≥1; AUC = 0.603), and sleep factor (cutoff, ≥1; AUC = 0.609) remained the same. In the early cohort, the CMF factor was the strongest predictor of protracted recovery (cutoff, ≥23; AUC = 0.717), followed by the total PCSS (cutoff, ≥39; AUC = 0.695) and affective factor (cutoff, ≥2; AUC = 0.614). The affective factor (cutoff, ≥1; AUC = 0.642) and total PCSS (cutoff, ≥35; AUC = 0.592) were significant predictors in the late cohort, but the cutoff threshold was reduced. Conclusion: The findings indicate that PCSS symptom clinical cutoffs for identifying injury and recovery prognosis change on the basis of time since injury. Specifically, the combination of CMF, affective, and sleep factors is the best differentiator of athletes with SRC from controls regardless of time since injury. Furthermore, the CMF factor is the most robust predictor of prolonged recovery if the patient is within 1 week of SRC, whereas the affective factor is the most robust predictor of prolonged recovery if the patient is within 2 to 3 weeks of SRC.

Objective The present study explored the relationship between specific types of postconcussion symptoms and cognitive outcomes in student–athletes with chronic concussion symptoms. Method Forty student–athletes with chronic concussion symptoms were given a battery of neuropsychological tests and rated themselves on a variety of postconcussion symptoms, which included the following factors derived from prior work: Physical, Sleep, Cognitive, Affective, and Headache. Cognitive outcomes included performance on composites for the memory and attention/executive functioning speed tests, respectively. The following covariates were also explored: Sex, depression symptoms, number of previous concussions, and time since injury. Results Headache was the only individual symptom factor that significantly (p Conclusion Comparable to work examining symptom predictors of cognitive outcomes in acutely concussed samples, headache predicted worse attention/executive functioning performance. Additionally, we found that the longer athletes had been symptomatic since injury, the “worse” their memory functioning. Understanding how headache and the length of time an individual is symptomatic are related to cognitive outcomes can help inform treatment and recommendations for athletes with prolonged symptom recovery.

Objective The aim of the study was to assess factors determining the utilization of physical and occupational therapy in people with spinal cord injury. Design Data from the German Spinal Cord Injury study conducted in 2017 were analyzed. The 12-mo prevalence of physical therapy and occupational therapy utilization was determined. To identify underlying determinants, multivariable logistic regression was used. Results Of 1479 participants (response = 26.4%), 72.9% were male, with a mean (SD) age of 55.3 (14.6) yrs and a mean (SD) time since injury of 14.0 (12.0) yrs; 51.2% were people with paraplegia and 66.3% had an incomplete spinal cord injury. In the past 12 mos, 78.1% received physical and 29.3% occupational therapy. Physical therapy and occupational therapy were significantly associated with time since spinal cord injury occurrence, participation in lifelong care programs, and electric wheelchair dependency. Spinal cord injury characteristics, level of impairment, and time since spinal cord injury had a greater impact on occupational therapy than on physical therapy utilization. Conclusions The use of physical therapy and occupational therapy is much higher in Germans with spinal cord injury than in the general population and in people with similar neurological conditions. Further research should focus on the frequency of use and the types of interventions. Guidelines for lifelong care should include recommendations on physical therapy and occupational therapy.

Displaced subcapital phalangeal fractures of the middle or proximal phalanges occur primarily in children. The degree and direction of displacement, patient age and time since injury influence treatment decisions and patient outcomes. Delayed presentation with malunion and reduced joint motion is common. This paper presents a case series of displaced subcapital phalangeal fracture early malunions managed conservatively. Near complete remodelling of dorsal angular deformity was seen in all patients. Conservative management of phalangeal subcapital fracture malunions is a viable alternative to the complex procedure of corrective osteotomy.

Objective To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors. Setting Children's hospitals in the Midwestern/Western United States. Participants 381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago. Design Secondary data analysis of a multistudy cohort. Main measures Child Behavior Checklist (CBCL) administered pretreatment. Results Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys. Conclusions Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.

Objectives:We examined the long-term maintenance of treatment outcomes in patients with acquired brain injuries who participated in community-based neuropsychological rehabilitation (NR) programs, in a prospective, within-subject, longitudinal, partial double-blind cohort study.Methods:One hundred forty-three patients (39 females, mean age 33.5 years) who had experienced a brain injury (BI) (mean time since injury 3.95 years) were referred to a postacute community-based NR institute. Patients participated in one of the three programs aimed at improving their functional outcome: comprehensive–holistic neuropsychological rehabilitation, vocational-focused neuropsychological rehabilitation, and individual neuropsychological rehabilitation. Self-reported data regarding employment, community integration, perceived quality of life (PQoL), and mood were collected at program start and end, and annually for 3 years post program completion. Group placement was based on clinical considerations, such that the study did not aim to compare the programs, but rather to assess their long-term benefits.Results:Employment status and stability, community integration, and PQoL improved significantly after program completion and continued to improve for the following 3 years. The proportion of individuals with mood disturbances did not change during or after the programs.Conclusions:A clear consensus regarding BI rehabilitation is that long-term maintenance of treatment outcomes is imperative to its efficacy. Our findings suggest that postacute NR programs provide participants with various tools, skills, and psychological perspectives that they continue to gain from and generalize to real life after program completion, reflecting transformational processes with stable long-term benefits.

The aim of this study was to retrospectively interpret body composition in various wheelchair athletes. In total, 69 athletes (mean ± standard deviation; age 33 ± 11 years; body mass 65.1 ± 14.8 kg; height 169.9 ± 14.9 cm and time since injury 19 ± 11 years) from different national teams in wheelchair sports underwent a dual X-ray absorptiometry (DXA) measurement during the yearly medical check-up. The data showed a significant difference between total fat and total fat-free mass between male (fat mass: 15.1 ± 7.6 kg; fat-free mass: 51.8 ± 9.3 kg) and female (fat mass: 19.4 ± 7.8 kg; fat-free mass: 36.8 ± 7.6 kg) athletes (p = 0.032, p < 0.001). In contrast, no significant difference (p = 0.16, p = 0.07) in fat and fat-free mass between paraplegic, tetraplegic and non-SCI athletes was found. Comparing different sports, the lowest fat mass was found in paracycling athletes whereas curling game players showed the highest total fat mass. Basketball game players showed the highest fat-free mass (fat-free mass: 54.8 ± 10.1 kg). In tetraplegic athletes, difference in fat-free mass between left and right arms correlated with the upper extremity motor score. For the interpretation of the data it seems to be crucial, that many different parameters (i.e., gender, motor level of the injury) are taken into consideration in wheelchair athletes.

Background Traumatic brain injury (TBI) is one of the most prevalent injuries in the military with mild traumatic brain injury (mTBI) accounting for approximately 70–80 % of all TBI. TBI has been associated with diffuse and focal brain changes to structures and networks underlying cognitive-emotional processing. Although the anterior cingulate cortex (ACC) plays a critical role in emotion regulation and executive function and is susceptible to mTBI, studies focusing on ACC resting state functional connectivity (rs-fc) in Veterans are limited. Methods Veterans with mTBI (n = 49) and with no history of TBI (n = 25), ages 20–54 completed clinical assessments and an 8-minute resting state functional magnetic resonance imaging (rs-fMRI) on a 3 T Siemens scanner. Imaging results were analyzed with left and right ACC as seed regions using SPM8. Regression analyses were performed with time since injury. Results Seed-based analysis showed increased connectivity of the left and right ACC with brain regions including middle and posterior cingulate regions, preceneus, and occipital regions in the mTBI compared to the non-TBI group. Conclusions The rs-fMRI results indicate hyperconnectivity in Veterans with mTBI. These results are consistent with previous studies of recently concussed athletes showing ACC hyperconnectivity. Enhanced top-down control of attention networks necessary to compensate for the microstructural damage following mTBI may explain ACC hyperconnectivity post-mTBI.

Background Functional Electrical Stimulation (FES) cycling can benefit health and may lead to neuroplastic changes following incomplete spinal cord injury (SCI). Our theory is that greater neurological recovery occurs when electrical stimulation of peripheral nerves is combined with voluntary effort. In this pilot study, we investigated the effects of a one-month training programme using a novel device, the iCycle, in which voluntary effort is encouraged by virtual reality biofeedback during FES cycling. Methods Eleven participants (C1-T12) with incomplete SCI (5 sub-acute; 6 chronic) were recruited and completed 12-sessions of iCycle training. Function was assessed before and after training using the bilateral International Standards for Neurological Classification of SCI (ISNC-SCI) motor score, Oxford power grading, Modified Ashworth Score, Spinal Cord Independence Measure, the Walking Index for Spinal Cord Injury and 10 m-walk test. Power output (PO) was measured during all training sessions. Results Two of the 6 participants with chronic injuries, and 4 of the 5 participants with sub-acute injuries, showed improvements in ISNC-SCI motor score > 8 points. Median (IQR) improvements were 3.5 (6.8) points for participants with a chronic SCI, and 8.0 (6.0) points for those with sub-acute SCI. Improvements were unrelated to other measured variables (age, time since injury, baseline ISNC-SCI motor score, baseline voluntary PO, time spent training and stimulation amplitude; p > 0.05 for all variables). Five out of 11 participants showed moderate improvements in voluntary cycling PO, which did not correlate with changes in ISNC-SCI motor score. Improvement in PO during cycling was positively correlated with baseline voluntary PO (R2 = 0.50; p p > 0.05). The iCycle was not suitable for participants who were too weak to generate a detectable voluntary torque or whose effort resulted in a negative torque. Conclusions Improved ISNC-SCI motor scores in chronic participants may be attributable to the iCycle training. In sub-acute participants, early spontaneous recovery and changes due to iCycle training could not be distinguished. The iCycle is an innovative progression from existing FES cycling systems, and positive results should be verified in an adequately powered controlled trial. Trial registration ClinicalTrials.gov, NCT03834324. Registered 06 February 2019 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03834324. Protocol V03, dated 06.08.2015.

Post-traumatic knee stiffness can present after injuries around the knee and surgery. Management is guided by the type of initial injury, amount of range-of-motion loss, time since injury, and cartilage status. Cases refractory to conservative management may conventionally be treated with manipulation under anesthesia (MUA), arthroscopic lysis of adhesions, or open quadricepsplasty. We describe our arthroscopic technique of lysis of adhesions with anterior interval release and intraoperative MUA, which has been shown to provide sustainable range-of-motion improvement in a subset of patients with severe knee arthrofibrosis. Although technically demanding, this technique benefits from being minimally invasive, allows for direct visualization of intra-articular structures, and allows all-round arthroscopic release of adhesions to improve patellar mobility and decrease the risk of fracture prior to MUA. A rigorous postoperative formal physical therapy protocol and patient compliance are imperative to achieve good outcomes.

Objective To evaluate the role of time since injury on the factor structure of the Post-Concussion Symptom Scale (PCSS) for athletes after sustaining a sport-related concussion (SRC). Methods Adolescent athletes (n = 782) were dichotomized based on time since injury: 0–7 (EARLY; n = 321, age: 15.4 ± 1.9 years, 51.7% female), 8–14 (MIDDLE; n = 281, age: 15.8 ± 2.2 years, 54.8% female) and 15–30 days (LATE; n = 180, age: 15.6 ± 1.8 years, 52.8% female). An EFA was performed on the 22 variables of the PCSS for each of the three cohorts (primary factor loading of 0.6 to retain each item). Results EARLY had a five-component model (64% of total variance): 1) GLOBAL (18.0%; headache/dizziness/photosensitivity/phonosensitivity/difficulty concentrating), 2) FATIGUE/HYPERSOMNIA (16.4%; fatigue/drowsiness/mental fogginess/slowed down/hypersomnia), 3) AFFECTIVE (12.6%; more emotional/sadness), 4) INSOMNIA (9.0%; insomnia/trouble falling asleep), 5) SOMATIC (8.0%; vomiting/numbness). MIDDLE had a four-component model (63.1% of variance): 1) GLOBAL (19.4%; photosensitivity/headache/phonosensitivity/nausea/dizziness), 2) INSOMNIA/AFFECTIVE (14.4%; insomnia/more emotional/nervousness/trouble falling asleep), 3) SOMATIC/MEMORY (12.2%; difficulty remembering/numbness), and 4) HYPERSOMNIA (12.0%; drowsiness/hypersomnia). LATE had a four-component model (65.7% of variance): 1) VESTIBULAR/OCULAR (18.2%; vision/difficulty remembering/balance/fogginess/dizziness), 2) MIGRAINE (16.6%; photosensitivity/phonosensitivity/fatigue/headache), 3) AFFECTIVE (16.1%; sadness/nervousness/more emotional), and 4) INSOMNIA (7.6%; insomnia/trouble falling asleep). Conclusions The results of this study suggest greater time since injury modifies symptom factor structure in adolescent athletes with SRC. Specifically, symptom factors become more distinct with longer time since injury before first clinical visit. A GLOBAL symptom factor was observed for both EARLY and MIDDLE, but not in LATE. SOMATIC (i.e., numbness) was observed in EARLY/MIDDLE, but not LATE. Symptom factors in LATE seem to mirror concussion clinical sub-types from previous research (e.g., vestibular/ocular, migraine, affective, sleep).

Univariate and multivariate relationships between perfectionistic self-presentation and reactions to impairment and disability following spinal cord injury were examined. One hundred and forty-four adults with spinal cord injury (M = 48.18 years, SD = 15.96) completed self-report measures. Analyses revealed that, after controlling for time since injury and gender, perfectionistic self-presentation predicted six of eight reactions, shock, depression, and internalised anger particularly strongly. In addition, at multivariate level, perfectionistic self-presentation was positively related to non-adaptive reactions and negatively related to adaptive reactions. The findings suggest that perfectionistic self-presentation may contribute to poorer psychosocial adaptation to spinal cord injury.

Effective screening for mild traumatic brain injury (mTBI) is critical to accurate diagnosis, intervention, and improving outcomes. However, detecting mTBI using conventional clinical techniques is difficult, time intensive, and subject to observer bias. We examine the use of a simple visuomotor tracking task as a screening tool for mTBI. Thirty participants, 16 with clinically diagnosed mTBI (mean time since injury: 36.4 ± 20.9 days (95 % confidence interval); median = 20 days) were asked to squeeze a hand dynamometer and vary their grip force to match a visual, variable target force for 3 min. We found that controls outperformed individuals with mTBI; participants with mTBI moved with increased variability, as quantified by the standard deviation of the tracking error. We modeled participants' feedback response-how participants changed their grip force in response to errors in position and velocity-and used model parameters to classify mTBI with a sensitivity of 87 % and a specificity of 93 %, higher than several standard clinical scales. Our findings suggest that visuomotor tracking could be an effective supplement to conventional assessment tools to screen for mTBI and track mTBI symptoms during recovery.

This article presents a personal overview of nerve transfers and emphasizes the various factors that contribute to outcome following these surgeries. There is no "one result" for all nerve transfers. The results will vary depending on factors relating to the donor nerve and the recipient nerve, the degree of the surgical difficulty of the specific procedure, and issues relating to preoperative and postoperative rehabilitation. The general issues that influence all nerve injury and recovery, such as age of the patient, comorbidities, and time since injury, pertain to nerve transfers as well.

Objective To determine if there are differences in post-concussion symptom levels depending on 1) when physical therapy treatment is begun after the concussion and 2) the length of treatment. Method Retrospective chart review yielded 202 patients who sustained concussions and were referred for physical therapy. Participants/patients were assigned to independent groups based on time elapsed between concussion and physical therapy (0–14, 15–30, 31–60, 61–120, 121–365 days), and on months spent in treatment (1–4). Pre- and post- treatment scores were documented for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p Results All patients demonstrated improvements with treatment, with no significant differences in outcomes for time elapsed since injury (SCAT Symptom Score ( p = .80), SCAT Symptom Severity Score ( p = .97), CISS ( p = .61), DHI ( p = .65), mCTSIB ( p = .13)); or for months in treatment (SCAT Symptom Score ( p = .23), SCAT Symptom Severity Score ( p = .04), CISS ( p = .41), DHI ( p = .37), mCTSIB ( p = .50)). Conclusions Improvements were similar for all patients receiving post-concussive physical therapy, regardless of time between injury and treatment onset, and regardless of time spent in treatment. These results may have implications for clinical decision-making and for third party payors’ coverage of post-concussion treatment. Longer periods of treatment may not necessarily be of greater benefit and application of treatment if delayed may also be beneficial. Limitations to the study, such as its retrospective nature, lack of randomization, and convenience sample size are discussed.

Persisting post-concussive symptoms are challenging to treat and may delay return-to-work (RTW). The aims of this study were to describe a multidisciplinary and holistic vocational rehabilitation (VR) program for individuals with mild traumatic brain injury (mTBI) and to explore course and predictors of employment outcome during VR. The VR program was described using the Standard Operating Procedures (SOPs) framework. Further, a retrospective, cohort study on individuals with mTBI receiving VR was conducted based on clinical records (n = 32; 22% males; mean age 43.2 years; 1.2 years since injury on average). The primary outcome was difference in hours at work per week from pre- to post-VR, and the secondary outcome was change in a three-level RTW-status. Time since injury, age, sex, and loss of consciousness were investigated as predictors of the outcomes. The VR intervention is individually tailored and targets patients' individual needs. Thus, it may combine a variety of methods based on a biopsychosocial theoretical model. During VR, hours at work, 17.0 ± 2.2, p < 0.001, and RTW-status, OR = 14.0, p < 0.001, improved significantly with 97% having returned to work after VR. Shorter length of time since injury and male sex were identified as predictors of a greater gain of working hours. Time since injury was the strongest predictor; double the time was associated with a reduction in effect by 4.2 ± 1.4 h after adjusting for working hours at start of VR. In sum, these results suggest that individuals facing persistent problems following mTBI may still improve employment outcomes and RTW after receiving this multidisciplinary and holistic VR intervention, even years after injury. While results are preliminary and subject to bias due to the lack of a control group, this study warrants further research into employment outcomes and VR following mTBI, including who may benefit the most from treatment.

Context/Objective: To evaluate the availability and self-declared unmet need of assistive devices to compensate for impaired hand function of individuals with tetraplegia in Switzerland. Design: Cross-sectional survey. Setting: Community. Participants: Individuals with tetraplegia, aged 16 years or older, living in Switzerland. Interventions: not applicable. Outcome Measures: The self-report availability and unmet need of 18 assistive devices for impaired hand function was analyzed descriptively. The availability of devices was further evaluated stratified by sex, age, SCI severity, independence in grooming, time since injury, living situation, working status, and income. Associations between availability of devices and person characteristics were investigated using logistic regression analysis. Results: Overall 32.7% of participants had any assistive device for impaired hand function at their disposal. The most frequent devices were adapted cutlery (14.8%), type supports (14.1%), environmental control systems (11.4%), and writing orthosis (10.6%). In the bivariate analysis several factors showed significant associations with at least one assistive device. Nevertheless, when controlling for potential confounding in multivariate analysis only independence in grooming (adapted cutlery, environmental control systems, type support, speech recognition software), SCI severity (writing orthosis, type support), and sex (adapted kitchenware) remained significantly associated with the availability of the mentioned assistive devices. The self-declared unmet need was generally low (0.7% - 4.3%), except for adapted kitchenware with a moderate unmet need (8.9%). Conclusion: This study indicates that most individuals with tetraplegia in Switzerland are adequately supplied with assistive devices to compensate for impaired hand function. The availability depends mainly on SCI severity and independence in grooming.

BACKGROUND Development of an embedded performance validity test (PVT) is desired for visual memory tests. The goal of this study was to derive an embedded PVT for the Child and Adolescent Memory Profile (ChAMP) Objects visual memory subtest in youth with mild traumatic brain injury (MTBI). METHODS Children and adolescents (N = 91; mean age = 14.9 years, SD = 2.2, range = 8-18) on average 25.2 weeks (SD = 15.4) post-MTBI were administered ChAMP Objects. Two stand-alone PVTs (Test of Memory Malingering and Medical Symptom Validity Test) were administered, which allowed for grouping into valid (zero failed stand-alone PVTs) and invalid (both stand-alone PVTs failed). Cutoff scores for invalid performance on ChAMP Objects and Objects Delayed were established using failure on two PVTs as the criterion. RESULTS One in five youth (n = 19) failed both PVTs. Invalid performance was not associated with demographics or time since injury, but was significantly correlated with both ChAMP Objects (r = .53, p

STUDY DESIGN: Pilot retrospective study on the outcome of open surgery for grade III and IV haemorrhoids in patients with SCI. OBJECTIVE: Haemorrhoids and anal fissures are common in patients with spinal cord injury (SCI). Grade I to III haemorrhoids are usually managed medically or by surgical ligation. Grade III and IV haemorrhoids are treated with surgical haemorrhoidectomy in the general population, but not in patients with SCI, most probably due to fear of complications. SETTING: Fondation Hopale, Berck-sur Mer, France METHODS: The surgical database was searched for open haemorrhoidectomies performed between 2007 and 2016. Seventeen patients were included. There were mostly males with complete paraplegia, mean age: 50 years and mean time since injury: 15.9 years. Open haemorrhoidectomy (Milligan and Morgan) was performed for isolated haemorrhoids (n = 4), and combined with Leopold Bellan procedure (posterior anoplasty and internal sphincterotomy) for associated anal fissures (n = 13). Short-term follow-up was performed by the surgeon (post-operative weeks 2 and 6), long-term follow-up by telephone interview (mean 5.7 years, SD 1.9). RESULTS: At 6-weeks post-operative, no significant complications had occurred and all wounds had healed, however 1 patient had recurrence of anal fissure. At long-term follow-up, 75% of patients reported a significant improvement in anorectal symptoms. Recurrences were reported by 5 patients: 3 haemorrhoids (18%) and 2 anal fissures (25%). Anal incontinence occurred in 1 patient who required an anal plug. All patients maintained the same bowel programs as pre-operative. CONCLUSIONS: Open surgery procedures were well tolerated and should be considered in persons with SCI.

STUDY DESIGN: Prospective observational. OBJECTIVES: Examine changes in participation restriction and assistance needs in a sample of people with long-standing spinal cord injuries (SCIs). SETTING: Two British spinal centres. METHODS: The sample consisted of British ageing with SCI study participants who were seen at baseline (1990 or 1993) and in the final follow-up (2010). Outcome measures were the Craig Handicap Assessment and Reporting Technique–Short Form (CHART-SF) and interview questions about assistance needs. RESULTS: Eighty-five Ageing study participants took part in 2010; their mean age was 67.65 years and the mean time since injury was 46.26 years. The mean CHART-SF physical independence subscore decreased from 97.44 in 1990 to 91.26 in 2010, mobility from 95.58 to 82.10, occupation from 86.82 to 64.49 and social integration from 96.29 to 88.68 (all p

Objective Data regarding length of stay (LOS) in a rehabilitation programme after traumatic brain injury (TBI) are limited. The goal of this study was to examine the effect of LOS and disability on outcome following TBI. Methods Records from patients in a multidisciplinary rehabilitation programme at least 3 months after TBI were analysed retrospectively to study the influence of LOS on functional outcome at different levels of disability. Functional status was determined by the Mayo-Portland Adaptability Inventory (MPAI) and the Community Integration Questionnaire (CIQ). Patients were further grouped by time since injury of 3-12 months or over 1 year. Results Those with a mild and moderate disabilities and over 1 year chronicity showed improvements after 90 days of rehabilitation. Patients with a severe disability and over 1 year chronicity required at least 180 days to show improvements. Moderately and severely disabled patients with an injury chronicity of 3-12 months showed improvements in the MPAI after 90 days. However, further improvement was observed after 180 days in the severely disabled group. Conclusions Results suggest that both, level of disability and injury chronicity, should be considered when determining LOS. Data also show an association between LOS and changes in the MPAI and CIQ.

Background: To study the epidemiological factors of head trauma in paediatric patients at a tertiary care centre. Methods: 60 consecutive admitted patients of head trauma were studied and analysed as per set proforma. The study included details pertaining to time since injury, average duration of stay, age distribution, sex distribution, GCS at presentation, mode of injury, associated injuries, CT findings, type of management and outcome. The results were tabulated and analysed. Results: The average time of presentation since injury was 3 hours, average duration of stay was 4 days, 1-5 years was the most commonly affected age group. GCS at presentation was 15 in most cases, fall from height was the most common mode of injury, Contused lacerated wounds were the commonest external injuries, parietal bone fracture was the most common CT scan finding, 96% improved with conservative management. Conclusions: Head injury occurs commonly in preschool children due to fall from unprotected roof tops. The prognosis in majority of the cases is excellent.

Purpose:Use accelerometers to examine the physical activity behaviours of individuals following TBI undergoing inpatient rehabilitation.Method:Twenty-one individuals with Traumatic brain injury (TBI) undergoing inpatient rehabilitation (9 females, 12 males;Mage = 43.8 ± 14.7 years;MGCS = 9.1 ± 4.3;Mtime since injury = 40.8 ± 22.1 days;Mlength of stay (LOS) = 30 ± 14 days) wore accelerometers for an average of 8.4 ± 2.0 consecutive days (1440 minutes/day). Activity counts (AC) were collected at 1 minute epochs and descriptive statistics were calculated to assess intensity of activity and time spent being active and sedentary.Results:During scheduled therapy, time individuals completed an average of 161.4 ± 65.5 AC/minute, which decreased to 114.5 ± 51.3 during non-therapy time and 22.2 ± 10 when sleeping. Using population level cut points, individuals were on average considered inactive during therapy, inactive or sedentary during non-therapy time, and only one participant spent >1 minute in moderate intensity activity. The mean length of active and sedentary bouts was 9 minutes.Discussion:Findings indicate that the amount and intensity of activity completed is low amongst individuals completing inpatient rehabilitation after TBI, with the majority considered sedentary or inactive. While the sample is small, it is important to develop and implement safe and effective strategies to increase activity levels during rehabilitation.

The objective of this study was to determine the inter-rater reliability and validity of using a telephone-based version of the spinal cord injury–secondary conditions scale (SCI–SCS). A psychometric study was conducted. The study was conducted in Royal North Shore Hospital, Sydney, Australia. Forty people with a complete or an incomplete spinal cord injury. Inter-rater reliability was tested by comparing the telephone-based version of the SCI–SCS administered on two different days by two different telephone assessors. Validity was tested by comparing the telephone-based version of the SCI–SCS with the paper-based version of the SCI–SCS. The median (interquartile range) age and time since injury were 54 (48–63) years and 28 (14–35) years, respectively. The intraclass correlation coefficient (95% confidence interval) reflecting the agreement between the telephone-based version of the SCI–SCS administered on two different days by two different assessors was 0.96 (0.93–0.98). The corresponding value reflecting agreement between the telephone-based assessment and the paper-based assessment was 0.90 (0.83–0.95). The telephone-based version of the SCI–SCS is a simple and a quick questionnaire to administer that has both inter-rater reliability and validity. It may be useful as a way to screen for secondary health conditions in low- and middle-income countries where it is not always feasible to provide routine face-to-face follow-ups and where literacy may be a problem.

Objective To assess quality of life (QOL) in individuals with mild and moderate traumatic brain injury (TBI) and their relationship with demographic, posttraumatic insomnia, and injury-related factors. Method The present study was a cross-sectional study conducted at Sawai Man Singh Medical College and group of hospitals over a period of 6 months from January 2013 to June 2013. The groups studied consists of 204 patients of mild and moderate TBI between 14 days and 1 year postinjury and equal number of controls by recruiting close relatives of the patients for comparison. Patients were assessed on semistructured sociodemographic proforma along with WHOQOL BREF, insomnia severity index, and GCS to assess QOL, insomnia, and severity of TBI, respectively. Result The number of participants included was 204. Mean age was 33.34 years. QOL was found impaired in all four domains of patients with TBI as compared with control group. The most unsatisfying domain among all was environmental health. None of the sociodemographic variables were associated with impaired QOL in TBI except duration and severity of head injury. Patients with longer duration (time since injury) of TBI and higher GCS had better QOL. Patients with insomnia had significantly poor QOL compared with those with TBI without insomnia. Conclusion QOL is an important aspect to be considered while management of TBI is performed especially during follow-ups. Impact of severity and the duration of injury with associated sleep problems have significant bearing on QOL.