Characteristics of successful and unsuccessful completers of 3 postacute brain injury rehabilitation pathways

OBJECTIVE: To determine whether successful participants along different postacute brain injury rehabilitation pathways differ on demographic, injury-related, disability, and outcome variables. DESIGN: Secondary analysis of pre- and posttreatment, and 1-year follow-up data obtained in a previous study of specialized vocational services (SVS) for persons with brain injury. SETTING: Outpatient brain injury rehabilitation clinic. PARTICIPANTS: One hundred fourteen persons with acquired brain injury. INTERVENTIONS: Participants in 3 distinct rehabilitation pathways were studied: SVS only; SVS and a 3-h/wk community reintegration outpatient group; and SVS and 6-h/d comprehensive day treatment (CDT). Main Outcome Measures: Mayo-Portland Adaptability Inventory (MPAI); Vocational Independence Scale; and "success," as defined by community-based employment (CBE) at 1-year follow-up. RESULTS: The percentage (77%-85%) of participants in CBE at 1-year follow-up did not differ among the 3 pathways. CDT participants had more limited educational backgrounds, were less recently injured, and showed greater disability and more impaired self-awareness than those receiving limited intervention (ie, SVS or community reintegration outpatient group). MPAI scores for limited-intervention participants who were unsuccessful were similar in level to successful participants in CDT. Logistic regression models were developed to predict the probability of success with limited intervention and CDT. CONCLUSION: Different rehabilitation pathways result in CBE for a large percentage of persons with brain injury if the intensity of service is appropriately matched to the severity of the disability, the time since injury, and other participant characteristics.     

The relationship between neuropsychologic function and level of caregiver supervision at 1 year after traumatic brain injury

OBJECTIVES: To evaluate distribution of levels of caregiver supervision at 1 year after traumatic brain injury, and to determine neuropsychologic predictors of supervision level. DESIGN: Prospective longitudinal design, concurrent measurement of neuropsychologic function and supervision level. SETTING: Seventeen Traumatic Brain Injury Model Systems centers. PARTICIPANTS: A total of 563 adults tested at 1 year postinjury; and a subgroup of 452 studied for neuropsychologic function in the absence of impairment in mobility or basic self-care, as assessed by high FIM instrument motor scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Supervision level measured by scores on Supervision Rating Scale (SRS). RESULTS: Two thirds (69%) of the sample was rated as independent of supervision. Participants without significant dysfunction on motor FIM were grouped into supervision groups differing in intensity of time commitment from caregiver (independent, moderate supervision, heavy supervision). In univariate analyses, groups differed on demographic variables (education, race, productivity prior to injury), duration of altered consciousness, and all but 1 neuropsychologic measure. A binomial regression model (complementary log-log model) revealed that supervision at 1 year was predicted by education and scores on the Trail Making Test Part B and digits backward. CONCLUSIONS: Findings confirm the importance of preinjury status and measures of working memory and cognitive flexibility in predicting functional independence after TBI. The SRS appears prone to ceiling effects in persons followed prospectively after moderate to severe TBI.     

Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury

OBJECTIVE: To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI). DESIGN: Nonrandomized, controlled trial with a 2-year follow-up. SETTING: Nationwide rehabilitation center and level I trauma center, both in Finland. PARTICIPANTS: We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status. INTERVENTIONS: A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support. MAIN OUTCOME MEASURE: Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation. RESULTS: At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses. CONCLUSIONS: The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.     

A comparison of acute and postdischarge predictors of employment 2 years after traumatic brain injury

OBJECTIVE: To examine whether adding postdischarge psychosocial predictors to premorbid and injury-related variables improved the capacity to predict employment 2 years after rehabilitation for traumatic brain injury (TBI). DESIGN: Data were collected prospectively at 6 and 24 months after discharge from rehabilitation. Logistic regression analyses examined predictors of employment status. SETTING: Inpatient and community TBI rehabilitation service attached to a major Australian teaching hospital. PARTICIPANTS: Fifty-five patients with TBI, aged 16 or older, who were consecutively admitted to a brain injury unit with complete longitudinal data and who agreed to participate in the study. INTERVENTION: Measured injury severity (Glasgow Coma Scale scores, posttraumatic amnesia); functional independence (Functional Assessment Measure cognitive subscale) at admission and discharge from rehabilitation; self-report of employment (premorbid, postdischarge); postdischarge psychosocial status at 6 months and 2 years (Community Integration Questionnaire, General Health Questionnaire, Trauma Complaints List, Overt Aggression Scale, Alcohol Use Disorders Inventory Test, Satisfaction with Life Scale). MAIN OUTCOME MEASURES: Employment status (employed, unemployed) was used to reflect vocational outcome. Predictor variables comprised premorbid work status, injury-related variables (age, injury severity), and postdischarge variables (employment, community integration, psychologic, cognitive status). RESULTS: Adding postdischarge predictors to premorbid and acute variables significantly improved the ability to predict work status 2 years after rehabilitation. Age at the time of injury, premorbid employment status, work status, and psychologic distress 6 months postdischarge were significant predictors of employment. CONCLUSIONS: It is important to consider postdischarge psychologic well-being, in conjunction with premorbid and acute factors, in vocational interventions after TBI.     

Headache after moderate and severe traumatic brain injury: a longitudinal analysis

OBJECTIVES: To measure longitudinally headache (HA) after moderate and severe traumatic brain injury (TBI) and to examine potential association with demographic, injury, and psychologic factors. DESIGN: Cohort study. SETTING: Four Veterans Administration rehabilitation facilities (Minneapolis, Palo Alto, Richmond, Tampa) within the Defense and Veterans Brain Injury Center. PARTICIPANTS: Consecutive patients (military or veteran beneficiaries) with moderate or severe TBI (N=109) who during acute rehabilitation consented to data collection and who completed 6- and 12-month follow-up evaluations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: HA frequency, location, type, and incapacitation levels measured during prospective neurologic assessments. RESULTS: Nearly 38% (41/109) of patients had acute posttraumatic headache (PTHA) symptoms; most often in a frontal location (20/41), most often of daily frequency (31/41), and showing no relation to injury severity, emotional, or demographic variables. Postacutely, PTHA symptom severity declined within the group. Better individual improvement was associated with less anxiety and depression at 6-month follow-up. Almost all subjects (21/22) with PTHA symptoms that persisted into the 6-month follow-up period reported symptoms again at 12-month follow-up. CONCLUSIONS: PTHA severity in this sample of persons with moderate and severe TBI showed a pattern of improvement that leveled off by 6 months posthospitalization.     

Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI model systems

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.     

Return to productive activity after traumatic brain injury: relationship with measures of disability, handicap, and community integration.

OBJECTIVES: To identify which factors are associated with successful return to productive activity (RTPA) 1 year after hospitalization with traumatic brain injury (TBI) and to examine the relations between successful RTPA and other measures of impairment, disability, handicap, and integration into the community. DESIGN: Prospective study with 1-year follow-up. SETTING: Level I trauma center. PARTICIPANTS: One hundred five respondents from a cohort of 378 adults hospitalized with TBI admitted between September 1997 and May 1998. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Return to productive work 1 year after injury; Disability Rating Scale (DRS); and Community Integration Scale (CIQ). RESULTS: Of the 105 participants, 72% achieved RTPA. Logistic regression showed an association between RPTA and the following factors: premorbid educational level, premorbid psychiatric history, violent mechanism of injury, discharge status after acute hospitalization, prior alcohol and drug use, and injury severity. Handicap and community integration at 1-year postinjury, as measured by subscales of the DRS and the CIQ, were also associated with RTPA. CONCLUSION: Premorbid and injury-related variables and measures of handicap and community integration were associated with RTPA at 1 year. To understand and effectively support vocational pursuits in the TBI population, future studies are needed to define further causality and origin of these relationships.     

Dynamic imaging in mild traumatic brain injury: support for the theory of medial temporal vulnerability

OBJECTIVE: To determine whether patients with mild traumatic brain injury (TBI) and persistent postconcussive symptoms have evidence of temporal lobe injury on dynamic imaging. DESIGN: Case series. SETTING: An academic medical center. PARTICIPANTS: Twenty patients with a clinical diagnosis of mild TBI and persistent postconcussive symptoms were referred for neuropsychologic evaluation and dynamic imaging. Fifteen (75%) had normal magnetic resonance imaging (MRI) and/or computed tomography (CT) scans at the time of injury. INTERVENTIONS: Neuropsychologic testing, positron-emission tomography (PET), and single-photon emission-computed tomography (SPECT). MAIN OUTCOME MEASURES: Temporal lobe findings on static imaging (MRI, CT) and dynamic imaging (PET, SPECT); neuropsychologic test findings on measures of verbal and visual memory. RESULTS: Testing documented neurobehavioral deficits in 19 patients (95%). Dynamic imaging documented abnormal findings in 18 patients (90%). Fifteen patients (75%) had temporal lobe abnormalities on PET and SPECT (primarily in medial temporal regions); abnormal findings were bilateral in 10 patients (50%) and unilateral in 5 (25%). Six patients (30%) had frontal abnormalities, and 8 (40%) had nonfrontotemporal abnormalities. Correlations between neuropsychologic testing and dynamic imaging could be established but not consistently across the whole group. CONCLUSIONS: Patients with mild TBI and persistent postconcussive symptoms have a high incidence of temporal lobe injury (presumably involving the hippocampus and related structures), which may explain the frequent finding of memory disorders in this population. The abnormal temporal lobe findings on PET and SPECT in humans may be analogous to the neuropathologic evidence of medial temporal injury provided by animal studies after mild TBI.     

A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes

OBJECTIVE: To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching. PARTICIPANTS: One hundred fourteen Minnesota residents, ages 18 to 65 years, with acquired BI. MAIN OUTCOME MEASURES: Outcome: Five levels of Vocational Independence Scale (VIS). Predictor: Preinjury employment status (VIS) and years of education, severity of initial injury, time since injury, current impairment/disability as measured by the Rasch-analyzed Staff Mayo-Portland Adaptability Inventory (MPAI), and impaired self-awareness measured by staff rating and the difference between Staff MPAI and Survivor MPAI. RESULTS: At placement, 46% in independent work; 25% in transitional placements; 9% in long-term supported employment; 10% in sheltered work; and 10% not placed. At 1-year follow-up (n = 101), 53% in independent work; 19% in transitional placement; 9% in supported work; 6% in sheltered work; and 13% unemployed. Regression analyses showed time since injury and Rasch Staff MPAI predicted VIS at placement; only VIS at placement independently predicted VIS at 1-year follow-up; Rasch Staff MPAI and preinjury education level predicted time to placement. CONCLUSIONS: The MVCCS optimized vocational outcome after BI. Time since injury and impairment/disability best predicted vocational placement. Level of initial placement best predicted employment status at follow-up. Persons with greater disability required more extended time and more extensive rehabilitation services before placement.     

Outcome 3 to 5 years after moderate to severe traumatic brain injury

OBJECTIVE: To investigate neuropsychologic, emotional, and functional status and quality of life (QOL) 3 to 5 years after moderate to severe traumatic brain injury (TBI). DESIGN: Observational cohort. SETTING: Level I trauma center. PARTICIPANTS: Consecutive adult admissions with TBI involving intracranial abnormalities, prospectively followed up for 3 to 5 years, with 80% follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Neuropsychologic functioning (Paced Auditory Serial Addition Test, California Verbal Learning Test), emotional status (Center for Epidemiologic Studies Depression Scale, Brief Symptom Inventory), functional status (Functional Status Examination, Glasgow Outcome Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, employment), and perceived QOL. RESULTS: Significant functional limitations were observed in all areas. Recovery to preinjury levels ranged from 65% of cases in personal care to approximately 40% in cognitive competency, major activity, and leisure and recreation. Brain injury severity, measured by the modified Abbreviated Injury Scale, related to functional status and neuropsychologic functioning, but not to emotional or QOL measures. Length of impaired consciousness appeared to contribute to outcome more than did anatomic lesions. CONCLUSIONS: The results provide representative estimates of long-term morbidity in patients with TBI involving intracranial lesions. The magnitude of morbidity was high. Although direct costs of TBI have received the most attention, the long-term consequences and their cost implications are much larger, unfold over time, and are borne by the survivors, their families, and the public subsidy system.     

Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors

Purpose: To address the content of work-related difficulties and explore which variables are associated to or determinants of these difficulties in persons that suffered from Traumatic Brain Injury (TBI). Method: Papers published between 1993 and February 2015 were included. Quality was judged as poor, acceptable, good or excellent. Determinants were extracted from longitudinal data, associated variables from cross-sectional data; variables were grouped by similarity. Evidence was judged as strong if the same results were reported by two or more good studies; limited if reported by one good and some acceptable studies. Results: Forty-two papers were selected (25,756 patients). Work-related difficulties were referred as unemployment, job instability or job cessation. Strong evidence of impact was found for: low educational level, pre-injury unemployment, Glasgow Coma Scale score and TBI severity, length of stay in acute and rehabilitation settings, lower Functional Independence Measure scores and presence of cognitive disturbances. Discussion: Evidence on the effect of rehabilitation interventions on TBI patients’ work-related difficulties exists, but is poorly measured. Future studies should address the sustainability of holistic and tailored interventions targeting employees, employers and workplaces and aimed to reduce the gap between work duties and worker’s abilities, using appropriate assessment instruments measuring difficulties in work activities.

• Implications for rehabilitation

• Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.

• While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.

• Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.

     

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.     

Poster 30: Relationship between p300 and neuropsychologic test performance during early recovery from traumatic brain injury

Objective: To examine the relationship between P300 latency and amplitude and neuropsychologic test scores in persons with traumatic brain injury (TBI) during acute inpatient rehabilitation. Design: Prospective, consecutive sample. Setting: Traumatic Brain Injury Model Systems (TBIMS) acute inpatient rehabilitation center. Participants: 52 patients with TBI were evaluated using a standardized neuropsychologic battery and P300 classical oddball paradigm after obtaining 2 consecutive Galveston Orientation and Amnesia Test scores within the target range. Data of 27 patients (age, 33±15y; admission Glasgow Coma Scale score, 8.0±3.9) satisfied electrophysiologic criteria (at least 20 correct rare responses) and were further analyzed. Interventions: Not applicable. Main Outcome Measures: Standard TBIMS neuropsychologic test battery and P300 latencies and amplitudes. Results: As expected, analyses revealed significant associations between Cz and Pz amplitudes and neuropsychologic measures of sustained attention (Symbol Digit Modalities Test, Trail-Making Test). However, relationships between Cz and Pz latencies and neuropsychologic test performance were less evident. Conclusions: During early recovery from TBI, P300 amplitudes more than latencies reflect cognitive processes associated with speed of information processing and attention.     

Self-reported psychosocial health among adults with traumatic brain injury

OBJECTIVE: To measure the subjective psychosocial health of a population-based sample of adults with traumatic brain injury (TBI). DESIGN: Retrospective, cohort study involving a 1-year postinjury interview. SETTING: Sixty-two acute care, nonfederal hospitals in South Carolina. PARTICIPANTS: Persons (> or =15y) hospitalized with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The psychosocial health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Of the 7612 participants, 29% reported poor psychosocial health. Factors associated with poor psychosocial well-being included younger age, female sex, Medicaid coverage, no health insurance, inadequate or moderate social support, comorbidities (eg, a preinjury substance abuse problem), cognitive complaints, and some or a lot of limitation with activities of daily living. Only 36% of participants who reported poor psychosocial health reported receiving any mental health services. CONCLUSIONS: A substantial proportion of persons hospitalized with TBI reported poor psychosocial health at 1 year postinjury. To optimize recovery, clinicians need to ensure that patients' psychosocial health needs are addressed during the postacute period.     

Success in the workplace following traumatic brain injury: are we evaluating what is most important?

Purpose: Vocational outcome, and in particular full-time paid work, is considered an important indicator of successful rehabilitation following traumatic brain injury (TBI). However it has not been established that these outcomes adequately or accurately represent the values of the people with TBI. This paper describes a study exploring the experiences of individuals who attempted returning to work following TBI, with emphasis on factors that related to perceptions of 'success' or 'failure'.

Method: A phenomenological study, interviewing seven people with moderate to severe TBI was conducted. The interview data were analysed for themes relating to experiences of success or failure in the workplace. Community consultation provided additional perspectives in the interpretation and validation of results.

Results: The results of this study support in part the assumption that paid employment is indicative of success following TBI. Equally prevalent were findings that challenged this assumption, including situations where: (1) return to employment contributed to catastrophic personal events, (2) feelings of success were achieved even though paid employment was not, and (3) success in the workplace was associated with factors other than hours worked or pay earned.

Conclusions: This research suggests that the use of work placement as a measure of successful rehabilitation might misrepresent the perspective of individuals with TBI. A multi-factorial approach to evaluating vocational rehabilitation is recommended, which incorporates the subjective experience of work.     

Success in the workplace following traumatic brain injury: are we evaluating what is most important?

Purpose:?Vocational outcome, and in particular full-time paid work, is considered an important indicator of successful rehabilitation following traumatic brain injury (TBI). However it has not been established that these outcomes adequately or accurately represent the values of the people with TBI. This paper describes a study exploring the experiences of individuals who attempted returning to work following TBI, with emphasis on factors that related to perceptions of ‘success’ or ‘failure’.

Method:?A phenomenological study, interviewing seven people with moderate to severe TBI was conducted. The interview data were analysed for themes relating to experiences of success or failure in the workplace. Community consultation provided additional perspectives in the interpretation and validation of results.

Results:?The results of this study support in part the assumption that paid employment is indicative of success following TBI. Equally prevalent were findings that challenged this assumption, including situations where: (1) return to employment contributed to catastrophic personal events, (2) feelings of success were achieved even though paid employment was not, and (3) success in the workplace was associated with factors other than hours worked or pay earned.

Conclusions:?This research suggests that the use of work placement as a measure of successful rehabilitation might misrepresent the perspective of individuals with TBI. A multi-factorial approach to evaluating vocational rehabilitation is recommended, which incorporates the subjective experience of work.     

Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury

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.     

Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury

OBJECTIVE: To evaluate the effectiveness of an intensive cognitive rehabilitation program (ICRP) compared with standard neurorehabilitation (SRP) for persons with traumatic brain injury (TBI). DESIGN: Nonrandomized controlled intervention trial. SETTING: Community-based, postacute outpatient brain injury rehabilitation program. PARTICIPANTS: Fifty-six persons with TBI. INTERVENTIONS: Participants in ICRP (n=27) received an intensive, highly structured program of integrated cognitive and psychosocial interventions based on principles of holistic neuropsychologic rehabilitation. Participants in SRP (n=29) received comprehensive neurorehabilitation consisting primarily of physical therapy, occupational therapy, speech therapy, and neuropsychologic treatment. Duration of treatment was approximately 4 months for both interventions. MAIN OUTCOME MEASURES: Community Integration Questionnaire (CIQ); and Quality of Community Integration Questionnaire assessing satisfaction with community functioning and satisfaction with cognitive functioning. Neuropsychologic functioning was evaluated for the ICRP participants. RESULTS: Both groups showed significant improvement on the CIQ, with the ICRP group exhibiting a significant treatment effect compared with the SRP group. Analysis of clinically significant improvement indicated that ICRP participants were over twice as likely to show clinical benefit on the CIQ (odds ratio=2.41; 95% confidence interval, 0.8-7.2). ICRP participants showed significant improvement in overall neuropsychologic functioning; participants with clinically significant improvement on the CIQ also showed greater improvement of neuropsychologic functioning. Satisfaction with community functioning was not related to community integration after treatment. Satisfaction with cognitive functioning made a significant contribution to posttreatment community integration; this finding may reflect the mediating effects of perceived self-efficacy on functional outcome. CONCLUSIONS: Intensive, holistic, cognitive rehabilitation is an effective form of rehabilitation, particularly for persons with TBI who have previously been unable to resume community functioning. Perceived self-efficacy may have significant impact on functional outcomes after TBI rehabilitation. Measures of social participation and subjective well-being appear to represent distinct and separable rehabilitation outcomes after TBI.     

Measuring unmet needs and services among persons with traumatic brain injury

OBJECTIVES: (1) To develop a comprehensive list of needs and services appropriate for persons with traumatic brain injury (TBI); (2) to determine whether these needs and services formed unidimensional hierarchies from least common to most common; (3) to describe the relationship between unmet needs and services received; and (4) to estimate the extent to which a variety of demographic, injury, and service characteristics predict unmet needs. DESIGN: Statewide mailed survey. SETTING: Illinois communities. PARTICIPANTS: A total of 895 persons who had had a TBI recruited from Brain Injury Association members and rehabilitation service recipients. The median time post-TBI was 7 years; the median age was 37 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A 27-item instrument assessing service needs and utilization of services, and equal-interval measures of needs and services derived with Rasch analysis. RESULTS: The most prevalent unmet needs were improving memory or problem-solving skills (51.9%), increasing income (50.5%), and improving job skills (46.3%). The instrument defined unidimensional and reliable constructs of needs and services. Persons with greater unmet needs tended to receive fewer services; to report lower life satisfaction and worse medical health and psychologic well-being since injury; to be younger, single, black, dependent in 1 or more daily activities; and to have more recent injuries. CONCLUSIONS: The results show the common pattern of unmet needs and services and emphasize the importance of comprehensive, statewide assessment of services and needs in developing policies.