Impact of age on long-term recovery from traumatic brain injury

Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, O'Neil-Pirozzi TM, Whyte J, Carlile M, Diaz-Arrastia R. Impact of age on long-term recovery from traumatic brain injury.

Objective

To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI).

Design

Longitudinal cohort study.

Setting

Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

Participants

Subjects enrolled in the TBIMS national dataset.

Interventions

Not applicable.

Main Outcome Measures

Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended.

Results

Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (≥40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates.

Conclusions

This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.     

Major and minor depression after traumatic brain injury

Hart T, Brenner L, Clark AN, Bogner JA, Novack TA, Chervoneva I, Nakase-Richardson R, Arango-Lasprilla JC. Major and minor depression after traumatic brain injury.

Objective

To examine minor as well as major depression at 1 year posttraumatic brain injury (TBI), with particular attention to the contribution of depression severity to levels of societal participation.

Design

Observational prospective study with a 2-wave longitudinal component.

Setting

Inpatient rehabilitation centers, with 1-year follow up conducted primarily by telephone.

Participants

Persons with TBI (N=1570) enrolled in the TBI Model System database and followed up at 1-year postinjury.

Interventions

Not applicable.

Main Outcome Measures

FIM, Patient Health Questionnaire-9, Participation Assessment with Recombined Tools-Objective, Glasgow Outcome Scale-Extended, and the Satisfaction With Life Scale.

Results

Twenty-two percent of the sample reported minor depression, and 26% reported major depression at 1-year post-TBI. Both levels of depression were associated with sex (women), age (younger), preinjury mental health treatment and substance abuse, and cause of injury (intentional). There was a monotonic dose-response relationship between severity of depression and all 1-year outcomes studied, including level of cognitive and physical disability, global outcome, and satisfaction with life. With other predictors controlled, depression severity remained significantly associated with the level of societal participation at 1-year post-TBI.

Conclusions

Minor depression may be as common as major depression after TBI and should be taken seriously for its association to negative outcomes related to participation and quality of life. Findings suggest that, as in other populations, minor and major depression are not separate entities, but exist on a continuum. Further research should determine whether people with TBI traverse between the 2 diagnoses as in other patient groups.     

Driving and community integration after traumatic brain injury

Rapport LJ, Coleman Bryer R, Hanks RA. Driving and community integration after traumatic brain injury.

Objective

To examine resumption of driving after traumatic brain injury (TBI) and its relation to community integration.

Design

Cross-sectional cohort study; survey and cognitive data.

Settings

Inpatient rehabilitation hospital of the Traumatic Brain Injury Model Systems and community.

Participants

Persons (N=261) ranging from 3 months to 15 years postinjury.

Interventions

Not applicable.

Main Outcome Measures

Barriers to Driving Questionnaire, Driver Survey, Community Integration Measure, and Craig Hospital Assessment and Reporting Technique.

Results

Forty-four percent of survivors had resumed driving; of nondrivers, 48% reported a strong desire to resume driving. Nondriver survivors who sought to resume driving generally rated themselves as currently fit to drive, viewed themselves as having physical and cognitive profiles like those of survivor drivers, and reported their greatest barriers to driving as social and resource related. However, cognitive functioning was similar to nondriver survivors who did not seek to resume driving and significantly worse than survivors who were currently driving. Nondrivers showed poorer community integration than did drivers, even after accounting for injury severity, social support, negative affectivity, and use of alternative transportation. Use of alternative transportation was common among nondrivers, but it was unrelated to community integration outcomes. Cognitive functioning moderated risk of adverse incident: among survivors with low cognitive functioning and high self-estimates of driving ability, which is indicative of unawareness of deficit, adverse incidents showed positive relation to amount of driving and inverse relation to cognitive functioning.

Conclusions

Driving status has unique and independent association with post-TBI community integration. Additional research is needed to evaluate transportation barriers that undermine full engagement in community living after TBI and to determine which barriers to driving reflect valid risk to survivors and the public.     

Access to inpatient rehabilitation after violence-related traumatic brain injury

OBJECTIVES: To examine injury characteristics, demographics, and discharge disposition after traumatic brain injury of violent or nonviolent cause. DESIGN: Cohort study. SETTING: Level I trauma center. PARTICIPANTS: Patients (N=1807) admitted with a Head Abbreviated Injury Score (AIS) of 2 or more over a 2-year period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Injury cause was classified as violent or nonviolent. Discharge disposition was classified as home, inpatient rehabilitation, skilled nursing facility (SNF), and other. RESULTS: The violence group was more likely to be male, to include individuals from diverse racial groups, to have an alcohol level above the legal limit, to have a more severe Head AIS, and to have Medicaid funding and equal access to inpatient rehabilitation compared with the nonviolence group. The violence group, though, was more likely to be discharged to home than to inpatient rehabilitation and more likely to be discharged to inpatient rehabilitation than to an SNF. The nonviolence group had a longer acute care length of stay and a higher rate of injuries to other body systems. CONCLUSIONS: People with violence-related injuries often present unique rehabilitation challenges. After accounting for injury severity and demographics, there was no evidence of bias against the violently injured in gaining access to inpatient rehabilitation services.     

Employment after traumatic brain injury: differences between men and women

Corrigan JD, Lineberry LA, Komaroff E, Langlois JA, Selassie AW, Wood KD. Employment after traumatic brain injury: differences between men and women.

Objective

To determine whether there are sex differences in employment 1 year after traumatic brain injury.

Design

Prospective cohort.

Setting

Acute care hospitals in South Carolina and Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

Participants

Subjects in the TBIMS national dataset and the South Carolina Traumatic Brain Injury Follow-up Registry who were expected to be working before injury and followed at 1 year postinjury.

Interventions

Not applicable.

Main Outcome Measure

Change in employment from preinjury to 1 year postinjury.

Results

When other measured influences on change in hours worked were held constant, there were significant interactions for sex by age and sex by marital status. Compared with men, women were more likely to decrease hours or stop working, except in the oldest age group (55−64y) in which men were more likely to stop working. For women, there was a pattern showing better employment outcomes as age increased. Decreased employment for women was most evident for married women, who were much more likely to reduce hours or stop working. There was also a tendency for divorced women to be more likely to stop working when compared with divorced men.

Conclusions

These findings run counter to the current literature. Although definitive explanations must await future studies, causal factors arising from differential societal behavior toward women as well as discriminatory attitudes about women and employment deserve further study.     

Neuropsychologic and functional outcome after complicated mild traumatic brain injury

Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic and functional outcome after complicated mild traumatic brain injury.

Objective

To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery.

Design

A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury.

Setting

Rehabilitation hospital with a Traumatic Brain Injury Model System.

Participants

Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design.

Results

Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up.

Conclusions

When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.     

Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury

Kalmar K, Novack TA, Nakase-Richardson R, Sherer M, Frol AB, Gordon WA, Hanks RA, Giacino JT, Ricker JH. Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury.

Objectives

To determine (1) if more than 50% of patients with moderate to severe traumatic brain injury (TBI) who met study criteria can complete a battery of neuropsychologic tests in less than 75 minutes 2 to 6 weeks after injury regardless of posttraumatic amnesia (PTA) status; (2) which tests are most likely to be completed; and (3) range of scores obtained.

Design

Prospective multicenter observational study.

Setting

Acute inpatient neurorehabilitation hospitals.

Participants

Screened 543 Traumatic Brain Injury Model System patients with moderate to severe TBI; 354 were tested at 2 to 6 weeks postinjury.

Interventions

Not applicable.

Main Outcome Measure

Percentage of patients able to complete the neuropsychologic tests in less than 75 minutes.

Results

Two hundred eighteen (62%) patients completed the battery in 66 minutes on average. Mean interval from injury to testing was 28.3±7.1 days. Tests completed with the highest frequency were California Verbal Learning Test−II, FAS, and animal naming. Performance was less impaired (P<.001) on all measures for patients who had emerged from PTA.

Conclusions

Approximately two thirds of screened patients were able to complete a brief neuropsychologic test battery at 2 to 6 weeks postinjury, regardless of PTA status. Although patients out of PTA were less impaired on all test measures, confusion did not preclude participation in the test battery or prohibit assignment of test scores. Early neuropsychologic assessment after TBI is feasible even for many patients who are still in PTA.     

The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury

OBJECTIVE: To document recovery in persons who were in the minimally conscious state (MCS) for at least 1 month after traumatic brain injury (TBI). DESIGN: Patient series. SETTING: Participants who had been discharged from an inpatient rehabilitation unit. PARTICIPANTS: Eighteen people with TBI and their relatives. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Western Neuro Sensory Stimulation Profile, Disability Rating Scale (DRS), FIM instrument, Dementia Rating Scale, and Sydney Psychosocial Reintegration Scale (SPRS). RESULTS: Level of functioning at follow-up varied from extremely severe disability or greater on the DRS (n=4) to mild disability (n=1). These outcomes were corroborated by results of the FIM and the Dementia Rating Scale. All participants experienced some (44%) or major (56%) change in their level of psychosocial functioning on the SPRS compared with their preinjury level. There were no significant correlations between duration of time in the MCS and outcome on FIM, DRS, or SPRS. CONCLUSIONS: These results highlight the heterogeneity of outcome even after a prolonged duration of MCS after TBI. A large proportion of the patients was functionally independent in basic daily activities, although all experienced residual impairments and disabilities. The low correlation coefficients between duration of MCS and the outcome measures suggest that prognostic statements based on length of time a person is in the MCS cannot be made with confidence.     

Cholinergic augmentation with donepezil enhances recovery in short-term memory and sustained attention after traumatic brain injury

OBJECTIVE: To examine effects of donepezil on short-term memory and sustained attention in postacute patients with traumatic brain injury (TBI). DESIGN: A 24-week, randomized, placebo-controlled, double-blind crossover trial. SETTING: Outpatient clinics in 2 teaching hospitals. PARTICIPANTS: Eighteen postacute TBI patients with cognitive impairment. INTERVENTION: Patients were randomly assigned to group A or group B. Patients in group A received donepezil for the first 10 weeks and then a placebo for another 10 weeks. The 2 treatment phases were separated by a washout period of 4 weeks. Patients in group B received the preparations in the opposite order. MAIN OUTCOME MEASURES: Short-term memory and sustained attention were assessed by 2 indexes (Auditory Immediate Index [AII], Visual Immediate Index [VII]) of the Wechsler Memory Scale-III and the Paced Auditory Serial Addition Test (PASAT), at baseline, week 10, and week 24 of the trial. RESULTS: Intragroup comparison of different phases of the trial in both groups showed that donepezil significantly increased the testing scores of the AII and VII, as well as PASAT scores, compared with baseline. There was no significant change in the testing scores between assessment at baseline and the end of the placebo phase in group B. Intergroup comparison at the 10-week assessment showed significantly improved testing scores in group A with donepezil over group B with the placebo. The improved testing scores with donepezil in group A were sustained after the washout period and placebo phase, suggesting a carry-over effect of the medication. CONCLUSIONS: Donepezil increased neuropsychologic testing scores in short-term memory and sustained attention in postacute TBI patients. Cholinergic augmentation may be a viable approach to restore memory and attention after TBI.     

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.     

Children show decreased dynamic balance after mild traumatic brain injury

OBJECTIVE: To compare the balance skills of children after mild traumatic brain injury (TBI) with that of noninjured children matched for age, sex, and premorbid level of physical activity. DESIGN: Cohort study. SETTING: Pediatric trauma center. PARTICIPANTS: Thirty-eight children aged 7 to 16 years (mean, 12.2+/-2.8 y) were recruited in each group. Children with mild TBI had a mean Glasgow Coma Scale score of 14.8 and were considered normal on a neurologic assessment at hospital discharge. Noninjured children were friends of those with mild TBI. INTERVENTION: Assessments of balance were conducted at 1, 4, and 12 weeks after mild TBI and at corresponding time intervals for the controls. MAIN OUTCOME MEASURES: The balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), the Pediatric Clinical Test of Sensory Interaction for Balance (P-CTSIB), and the Postural Stress Test (PST) were used. RESULTS: Over the time interval of the study, analyses of variance revealed that children with mild TBI performed significantly worse than the noninjured group on the BOTMP balance subtest (P<.001) and on the PST (P=.031), as well as on the eyes-closed conditions in the P-CTSIB tandem position (P=.05). CONCLUSIONS: Children with a mild TBI still showed balance deficits at 12 weeks postinjury. These deficits should be taken into consideration when planning a return to physical activities, particularly to those that require subtle balance skills.     

Recovery of ambulation after traumatic brain injury

OBJECTIVES: To identify variables that are predictive of independent ambulation after traumatic brain injury (TBI) and to define the time course of recovery. DESIGN: Retrospective review of consecutive admissions of patients with severe TBI over a 32-month period. SETTING: Brain injury unit in an acute, inpatient rehabilitation hospital. PARTICIPANTS: Of 264 patients screened, 116 met criteria that included the ability to participate in motor and functional evaluation on admission to acute rehabilitation, and the absence of other neurologic disorders or fractures that affect one's ability to ambulate. INTERVENTION: Inpatient rehabilitation on a specialized TBI unit by an interdisciplinary team.Main outcome measures Recovery of independent ambulation and time to recover independent ambulation. RESULTS: Of eligible patients, 73.3% achieved independent ambulation by latest follow-up (up to 5.1 mo). Patients who achieved independent ambulation were significantly younger (P<.05), had better gait scores on admission (P<.05), and tended to be less severely injured-based on duration of posttraumatic amnesia (PTA; P=.058)-than those who did not ambulate independently. There were no differences in recovery based on neuropathologic profile. Mean time to independent ambulation +/- standard deviation was 5.7+/-4.3 weeks; of those achieving independent ambulation, 82.4% did so by 2 months and 94.1% by 3 months. If not independent by 3 months postinjury, patients had a 13.9% chance of recovery. Multivariate regression analysis generated prediction models for time to independent ambulation, using admission FIM instrument scores and age (38% of variance); initial gait score, loss of consciousness, and age (40% of variance); or initial gait score and PTA (58% of variance), when restricted to just those patients with diffuse axonal injury. CONCLUSIONS: Most patients with severe TBI achieved independent ambulation; the vast majority did so within 3 months postinjury. Functional measures, injury severity measures, and age can help guide prognosis and expectations for time to recover.     

Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged

Altman IM, Swick S, Parrot D, Malec JF. Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged.

Objective

To evaluate outcomes of home- and community-based postacute brain injury rehabilitation (PABIR).

Design

Retrospective analysis of program evaluation data for treatment completers and noncompleters.

Setting

Home- and community-based PABIR conducted in 7 geographically distinct U.S. cities.

Participants

Patients (N=489) with traumatic brain injury who completed the prescribed course of rehabilitation (completed-course-of-treatment [CCT] group) compared with 114 who were discharged precipitously before program completion (precipitous-discharge [PD] group).

Intervention

PABIR delivered in home and community settings by certified professional staff on an individualized basis.

Main Outcome Measures

Mayo-Portland Adaptability Inventory (MPAI-4) completed by means of professional consensus on admission and at discharge; MPAI-4 Participation Index at 3- and 12-month follow-up through telephone contact.

Results

Analysis of covariance (CCT vs PD group as between-subjects variable, admission MPAI-4 score as covariate) showed significant differences between groups at discharge on the full MPAI-4 (F=82.25; P<.001), Ability Index (F=50.24; P<.001), Adjustment Index (F=81.20; P<.001), and Participation Index (F=59.48; P<.001). A large portion of the sample was lost to follow-up; however, available data showed that group differences remained statistically significant at follow-up.

Conclusions

Results provided evidence of the effectiveness of home- and community-based PABIR and that treatment effects were maintained at follow-up.     

Comparison between successful and failed sit-to-stand trials of a patient after traumatic brain injury

OBJECTIVE: To compare the peak whole-body center of mass (COM) velocities and joint angular contributions in successful and unsuccessful sit-to-stand (STS) trials in a subject with traumatic brain injury (TBI). DESIGN: Single-case study. SETTING: Motion research laboratory. PARTICIPANT: A 24-year-old man who was 3.5 years post-TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak horizontal and vertical velocities of the whole-body COM and peak angular velocities of the ankle, knee, hip, and shoulder joints. RESULTS: The peak whole-body COM vertical velocity was significantly lower in the unsuccessful STS trials. Angular velocities at the hip, knee, ankle, and shoulder joints in successful trials exceeded those in unsuccessful trials (P<.001). The subject's peak knee extension velocity was the single major predictor of the peak whole-body COM vertical velocity (r(2)=.90). Knee extension angular velocities greater than 3.25 radian/s were associated with successful STS trials. Knee extension angular velocities between 2.75 and 3.25 radian/s were associated with successful rising 50% of the time; the subject had no success in rising when velocities were less than 2.75 radian/s. CONCLUSIONS: For this subject, sit-back failures occurred in STS attempts characterized by peak whole-body COM vertical velocities that were lower than those generated in successful rising trials. These unsuccessful rising attempts were primarily the result of the subject's inability to generate sufficient knee extension angular velocity.     

Outcome after mild to moderate traumatic brain injury: the role of dizziness

OBJECTIVE: To assess the specific effect of dizziness on psychosocial outcome after mild to moderate traumatic brain injury (TBI). DESIGN: Six-month cross-sectional study. Setting An outpatient TBI clinic in a tertiary care referral center. Participants A consecutive sample of 207 adults with mild to moderate TBI, 138 (66.7%) of whom had subjective complaint of posttraumatic dizziness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Psychosocial indices (Glasgow Outcome Scale [GOS], General Health Questionnaire [GHQ], Rivermead Head Injury Follow-Up Questionnaire [RHFUQ], return to work status) were collected from dizzy and nondizzy patients. RESULTS: Despite similar demographic, TBI, and global disability (GOS) profiles of both groups, psychosocial functioning (GHQ, RHFUQ, return to work) was significantly worse in dizzy subjects ( P <.01 for all indices). A logistic regression analysis identified dizziness ( P =.006), total GHQ ( P =.001), and psychotropic and analgesic use ( P =.05) as significant independent predictors of reemployment. CONCLUSIONS: Although dizziness was closely linked to psychologic distress at 6 months after head injury, it also emerged as an independent predictor of failure to return to work, suggesting that not all its adverse effects on outcome are psychologically mediated. Clinicians need to be alert to the presence of dizziness as an adverse prognostic indicator after mild to moderate TBI.     

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.     

Sex differences in injury severity and outcome measures after traumatic brain injury

OBJECTIVE: To investigate the effect of a patient's sex on various measures of injury severity and outcome after rehabilitation in a matched sample of patients with traumatic brain injury (TBI). DESIGN: Retrospective data were retrieved from a database that contains information routinely collected on all patients admitted for inpatient rehabilitation. SETTING: Inpatient rehabilitation unit of major teaching hospital in Australia. PARTICIPANTS: Fifty-four women with TBI after a motor vehicle crash (MVC) were identified from the Brain Injury Rehabilitation Database. An equal number of men were then matched for age and years of education. All subjects met the study admission criteria of having being involved in a high-speed MVC. Exclusion criteria included history of a previous head injury, chronic amnesia, psychiatric disturbance, and significant alcohol and/or substance abuse. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Differences, by sex, in patient scores on measures of injury severity and outcome after TBI. RESULTS: Men had significantly greater levels of injury severity as indicated by the Glasgow Coma Scale scores (U=994.0, P=.002) and length of posttraumatic amnesia (U=880.0, P=.016) when compared with women. No significant sex differences existed in the outcome measures or in injuries not associated with the central nervous system. CONCLUSIONS: Few investigations exist on the effect of patient sex on measures of injury severity and outcome after a TBI. In the present study, men's levels of injury severity were greater than women's despite the same admission criteria (high-speed MVC) being applied to both sexes.