Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Reliability of peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury

OBJECTIVE: To examine the test-retest reliability of acute physiologic responses in patients with traumatic brain injury (TBI). DESIGN: Repeated measures within 1 week. SETTING: Brain injury rehabilitation program and community rehabilitation hospital. PARTICIPANTS: Thirty-six inpatients or their legal guardians. INTERVENTIONS: Each patient performed a symptom-limited incremental cycle ergometer test to voluntary fatigue on 2 separate occasions within 1 week. MAIN OUTCOME MEASURES: Peak values of power output and cardiorespiratory responses measured with a metabolic cart interfaced with an electrocardiogram. RESULTS: Intraclass correlations between the 2 trials were as follows: power output,.96; absolute oxygen uptake,.98; relative oxygen uptake,.97; heart rate,.82; ventilation rate,.96; and respiratory exchange ratio,.81. Bland-Altman plots showed that all data points were within the 95% confidence limits of the mean value of the 2 trials for each variable. CONCLUSIONS: The reliability of the peak cardiorespiratory responses during non-weight-bearing exercise was high in patients with TBI in a controlled laboratory setting. Therefore, aerobic exercise programs can be accurately prescribed, and changes resulting from such interventions can be confidently evaluated in this population.     

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.     

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.     

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.     

Branched-chain amino acids enhance the cognitive recovery of patients with severe traumatic brain injury

OBJECTIVE: To investigate whether supplementation with branched-chain amino acids (BCAAs) in patients with severe traumatic brain injury (TBI) improves recovery of cognition and influences plasma concentrations of tyrosine and tryptophan, which are precursors of, respectively, catecholamine and serotonin neurotransmitters in the brain. DESIGN: Forty patients with TBI were randomly assigned to 15 days of intravenous BCAA supplementation (19.6g/d) (n=20) or an isonitrogenous placebo (n=20). SETTING: Tertiary care rehabilitation setting in Italy. PARTICIPANTS: Forty men (mean age, 32+/-15 y) with TBI and 20 healthy subjects (controls) matched for age, sex, and sedentary lifestyle. INTERVENTION: Supplementation with BCAAs. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS) and plasma concentrations of BCAAs, tyrosine, and tryptophan. RESULTS: Fifteen days after admission to the rehabilitation department, the DRS score had improved significantly in both the placebo group (P<.05 vs baseline) and in the BCAA-supplemented group (P<.01 vs baseline). The difference between the 2 groups was significant (P<.004). Plasma tyrosine concentration improved in the group given BCAA supplementation, and tryptophan concentration increased in patients receiving placebo. CONCLUSIONS: Supplemental BCAAs enhance the retrieval of DRS without causing negative effects on tyrosine and tryptophan concentration.     

Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury

OBJECTIVE: To examine the time course of the changes in body composition and peak cardiorespiratory fitness resulting from routine brain injury rehabilitation program (BIRP) activities and circuit training in patients with moderate to severe traumatic brain injury (TBI). DESIGN: Time-series design spanning 18 weeks. Trials T1 and T2 were completed in weeks 1 and 2, respectively, to establish reliability of the measurements, followed by trial 3 (T3) 4 weeks later to evaluate changes resulting from the BIRP. SETTING: A BIRP in a community rehabilitation hospital. PARTICIPANTS: Fourteen inpatients with moderate to severe acquired TBI (Glasgow Coma Scale score, 4.6+/-1.4; time since injury, 17.2+/-17 mo). INTERVENTIONS: Twelve-week circuit-training program designed to enhance muscular strength and endurance and aerobic fitness. Subjects were tested midway (T4) through the program and at the end (T5) of 12 weeks. The patients completed an average of 32 supervised sessions, each lasting 1 hour. MAIN OUTCOME MEASURES: Changes in body composition and peak cardiorespiratory responses. RESULTS: No significant changes were observed in the body mass or percentage body fat during the study. The peak values of power output, oxygen uptake, and ventilation rate increased significantly as a result of training, with no concomitant increases in peak heart rate or blood lactate (T5>T3, T2, T1; P <.05). No significant changes were evident midway through training. CONCLUSIONS: In a heterogeneous sample of patients with moderate to severe TBI, (1) body composition and peak cardiorespiratory responses remained fairly stable during 6 weeks of BIRP activities, (2) improvements in peak cardiorespiratory fitness required more than 6 weeks of circuit training, and (3) a 12-week course of circuit training without controlling caloric intake was not effective in reducing body weight or percentage body fat.     

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.     

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.     

Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury

Hansen TS, Engberg AW, Larsen K. Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury.

Objectives

To investigate the status of functional oral intake for patients with severe traumatic brain injury (TBI) and time to return to unrestricted dieting; and to investigate whether severity of brain injury is a predictor for unrestricted dieting.

Design

Observational retrospective cohort study.

Setting

Subacute rehabilitation department, university hospital.

Participants

Patients age 16 to 65 years (N=173) with severe TBI (posttraumatic amnesia from 7d to >6mo) admitted over a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously.

Intervention

Facial oral tract therapy.

Main Outcome Measure

Unrestricted dieting assessed by the Functional Oral Intake Scale (FOIS).

Results

We found that 93% of all patients had problems with functional oral intake at admission. Within 126 days of rehabilitation, 64% recovered to unrestricted dieting before discharge. The chance of returning to total oral diet depends on the severity of the brain injury and can be predicted by Glasgow Coma Scale (GCS; measured the day after cessation of sedation; Wald χ²=42.78, P<.01), Rancho Los Amigos Scale (RLAS) level (Wald χ²=11.84, P=.01), FIM instrument (Wald χ²=44.40, P<.01), and FOIS score at admission (Wald χ²=82.93, P<.01).

Conclusions

Impairment in functional oral intake was found to be very common for patients with severe TBI admitted to a subacute rehabilitation department. For those who recovered during hospital rehabilitation, return to unrestricted dieting happened within 126 days of rehabilitation. The chance of returning to unrestricted dieting depends on the severity of the brain injury and can be predicted by GCS score, RLAS level, FIM score, and functional oral intake at admission. These results are important when planning rehabilitation, giving information to patients and relatives, and designing efficacy studies of facial oral tract therapy, which are highly recommended.     

Hyperbaric oxygen therapy for traumatic brain injury: still an enigma

Masel BE. Hyperbaric oxygen therapy for traumatic brain injury: still an enigma.With their article on the use of HBOT for post TBI dysautonomia, Lv and colleagues discuss a novel use for this form of treatment. Although HBOT has been a part of our TBI treatment armamentarium for many years, its use remains a very controversial issue. In this commentary, the science and research studies behind HBOT for TBI are reviewed, hopefully leaving the reader with an adequate knowledge base to answer a patient or family's inquiries as to the usefulness of HBOT for TBI.     

Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury

OBJECTIVE: To compare awareness of deficit in 3 domains of function (physical, cognitive, behavioral/emotional) in acute traumatic brain injury (TBI), controlling for severity of impairment in the different domains. DESIGN: Inception cohort. SETTING: Three inpatient rehabilitation programs. PARTICIPANTS: People with acute TBI (N=161), tested as soon as feasible after posttraumatic amnesia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Awareness Questionnaire (AQ) completed by the person with TBI and the treating neuropsychologist; and self- and clinician-rating scores calculated in the 3 domains. RESULTS: For participants who were rated by clinicians as more impaired in at least 1 domain (ie, scored lower on the AQ), self-ratings differed significantly from one another in all 3 domains, with behavioral self-ratings highest, physical self-ratings lowest, and cognitive self-ratings intermediate. In subgroups of participants rated at the same level by clinicians in all 3 domains, physical self-ratings were also lowest, that is, more consonant with clinician ratings. Participants tended to rate themselves as relatively unchanged in cognitive and behavioral domains regardless of the level of clinician ratings on these factors. CONCLUSIONS: Patterns of discrepant awareness of deficit in different functional areas seen in postacute TBI also appear to be present acutely and are not entirely related to differential severity of deficit. We discuss several possible reasons for discrepant awareness of deficit, including differences in internal and external feedback, cultural and psychologic factors, and different levels of ambiguity inherent in causal explanations for different types of problems.     

Multidimensional assessment of acute confusion after traumatic brain injury

OBJECTIVES: To describe the phenomenology of posttraumatic confusional state (PTCS) and to provide preliminary validation of a new procedure, the Confusion Assessment Protocol (CAP), for assessing PTCS. DESIGN: Criterion standard investigation. SETTING: Inpatient traumatic brain injury (TBI) rehabilitation program. PARTICIPANTS: Two consecutive series of patients (n=62, n=93) with TBI admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, classification of posttraumatic amnesia (PTA) based on the Galveston Orientation and Amnesia Test (GOAT), and Disability Rating Scale score at time of rehabilitation hospital discharge. Results Agreement between the diagnosis of PTCS with the CAP and DSM-IV classification of delirium was 87%, and agreement between PTCS and PTA using GOAT criteria was 90%. Patients classified as in PTCS sustained more severe injuries and required longer rehabilitation stays. Confusion status was associated with poorer functional status at rehabilitation discharge. CONCLUSIONS: The CAP is a brief, structured, repeatable measure of multiple neurobehavioral aspects of PTCS. Confusion status as determined by CAP assessment contributed to prediction of outcome at rehabilitation discharge after adjustment for other potential predictors.     

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.     

The association of functional oral intake and pneumonia in patients with severe traumatic brain injury

Hansen TS, Larsen K, Engberg AW. The association of functional oral intake and pneumonia in patients with severe traumatic brain injury.

Objectives

To investigate the incidence and onset time of pneumonia for patients with severe traumatic brain injury (TBI) in the early phase of rehabilitation and to identify parameters associated with the risk of pneumonia.

Design

Observational retrospective cohort study.

Setting

Subacute rehabilitation department in a university hospital in Denmark.

Participants

Patients (N=173) aged 16 to 65 years with severe TBI who were admitted during a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously.

Interventions

Not applicable.

Main Outcome Measure

Pneumonia.

Results

Twenty-seven percent of the patients admitted to the brain injury unit were in treatment for pneumonia; pneumonia developed in 12% of the patients during rehabilitation; the condition occurred within 19 days of admission in all but 1 patient. Of these patients, 81% received nothing by mouth. Three factors identified patients at highest risk of pneumonia: Glasgow Coma Scale score less than 9 (1 day after cessation of sedation); Rancho Los Amigos Scale score less than 3 (on admission); and no oral intake on admission. Having a tracheotomy tube and/or feeding tube was also associated with a higher occurrence of pneumonia.

Conclusions

Among patients with severe TBI, 27% had pneumonia at transfer from the intensive care unit. Pneumonia developed in only 12% of the participants during rehabilitation. Patients with a low level of consciousness and patients with a tracheotomy tube or feeding tube had a higher likelihood of pneumonia.     

Cognitive behavioral therapy for insomnia associated with traumatic brain injury: a single-case study

OBJECTIVE: To test the efficacy of a cognitive behavioral therapy (CBT) for insomnia with a patient with traumatic brain injury (TBI). DESIGN: Single-case study. SETTING: Outpatient rehabilitation center. PARTICIPANT: A man in his late thirties who sustained a moderate TBI in a motor vehicle crash and who developed insomnia. He complained of difficulties falling asleep and staying asleep, despite pharmacotherapy with zopiclone. INTERVENTIONS: Eight weekly individual CBT sessions. Treatment included stimulus control, sleep restriction, cognitive therapy, and sleep hygiene education. MAIN OUTCOME MEASURES: Sleep diary and polysomnography data. RESULTS: Sleep onset decreased from 47 to 18 minutes, and nocturnal awakenings dropped from 85 to 28 minutes on average at posttreatment. Sleep efficiency also increased substantially (58% to 83%). Polysomnography evaluations corroborated the diary data by showing a decrease in total time awake (63.2 to 26.3 min) and in the number of awakenings (21 to 7.5). The majority of gains were well maintained at 1- and 3-month follow-up assessments. CONCLUSIONS: These preliminary results suggest that sleep disturbances after TBI can be alleviated with a nonpharmacologic intervention. CBT for post-TBI insomnia is a promising therapeutic avenue deserving more scientific and clinical attention.     

Longitudinal study of inpatients admitted to a general activation service: variables that predict discharge to a patient's discharge goal location

OBJECTIVE: To determine which sociodemographic and clinical characteristics of patients admitted to a general activation service (GAS) are predictive of discharge to patients' discharge goal locations (DGLs). DESIGN: Prospective cohort study. SETTING: Rehabilitation and complex continuing care hospital in southern Ontario, Canada. PARTICIPANTS: Patients admitted from January 2000 to December 2002 (N=154). INTERVENTION: The GAS. MAIN OUTCOME MEASURE: Patients indicated on their service applications where they wanted to be discharged. This is termed the DGL. RESULTS: Fifty-three percent of the sample were discharged to their DGLs. Ninety-eight percent of these patients were discharged by 9 months. Eighty-seven percent who were discharged to their DGLs were discharged to their own home. Predictors of being discharged to the DGL were better activities of daily living scores, good vision, and having sufficient help at home. Expert clinician opinion of the likelihood of each patient being discharged to his/her DGL, based on initial assessment, was also predictive of each patient's eventual discharge to his/her DGL. CONCLUSIONS: The GAS has a 53% success rate in discharging patients to their DGLs. Variables have been identified that should be useful in predicting whether patients will be discharged to their DGLs. Our findings are meaningful and informative in determining future admission criteria for the service.     

Evaluation of the errorless learning technique in children with traumatic brain injury

OBJECTIVE: To compare errorless learning with trial-and-error (T&E) learning of declarative facts in children with memory disorders secondary to traumatic brain injury (TBI). DESIGN: Retrospective within-subjects concurrent treatment design. SETTING: Participants' school or home. PARTICIPANTS: Thirty-four children, ages 6 to 18 years, with mild, moderate, or severe postacute TBI who met criteria for memory impairment. INTERVENTION: Conditions consisted of an errorless learning method and a T&E method. Within a session, half the items were taught with the errorless learning method and half with the T&E method. Each child received two 1-hour sessions a week for 7 weeks. MAIN OUTCOME MEASURES: Relative effectiveness of errorless learning and T&E methods for (1) initial learning and (2) retention over time for learned items. RESULTS: There was an advantage for T&E on initial learning. In children with mild, but not moderate or severe TBI, 2-day retention was better with the errorless learning technique; 7-day retention was better with errorless learning in young children with mild TBI. Seventy-seven-day retention revealed an advantage for errorless learning in younger children with severe TBI. CONCLUSIONS: Findings did not support errorless learning as a generalized intervention for learning difficulties after TBI or identify specific age- or injury-severity groups that benefited from this technique.