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.     

Validation of a model for evaluating outcome after traumatic brain injury

OBJECTIVE: To validate a model that examines the contribution of premorbid variables, injury severity, and functional and cognitive status to outcome 1 year after traumatic brain injury (TBI). DESIGN: Cross-validation study using a larger, national, prospective, longitudinal sample. SETTING: Acute inpatient rehabilitation hospitals at Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Two sample populations followed through acute rehabilitation to 1 year after TBI. The original sample included 107 patients, and the cross-validation sample included 294 patients. Participants were predominantly young men who had experienced moderate to severe TBI in motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. RESULTS: Structural equation modeling was used to compare the fit of the data to a path analysis developed through clinical use and previous research. Both samples provided adequate goodness of fit, supporting the model's validity. Injury severity affected cognitive and functional status, and cognitive and functional status significantly influenced 1-year outcome. Premorbid factors and injury severity did not directly influence outcome. CONCLUSIONS: Both samples supported the proposed model, which was cross-validated. Injury severity indirectly influences outcome through its effects on cognitive and functional status. Although treatment to decrease injury severity is obviously important, concentrated rehabilitation interventions aimed at improving patients' cognitive and functional status may have a more significant impact on 1-year outcome and should be the focus of future research.     

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

Vickery CD, Sherer M, Nick TG, Nakase-Richardson R, Corrigan JD, Hammond F, Macciocchi S, Ripley DL, Sander A. Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury.

Objective

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

Design

Prospective cohort study.

Setting

Acute inpatient TBI rehabilitation.

Participants

Participants were 1748 persons with TBI.

Interventions

Not applicable.

Main Outcome Measures

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

Results

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

Conclusions

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.     

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.     

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.     

Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury.

OBJECTIVE: To examine functional improvement patterns of persons with stroke, traumatic brain injury (TBI), and spinal cord injury (SCI). DESIGN: Statistical analysis of data from a multisite study evaluating rehabilitation outcomes. SETTING: Eight inpatient rehabilitation facilities. PARTICIPANTS: A total of 314 consecutive admissions of persons with stroke, SCI, and TBI who received acute medical rehabilitation between 1994 and 1998. INTERVENTION: Calibration of motor and cognitive items from the FIM instrument, grouping of cases by number of weeks of rehabilitation (length of stay [LOS] groups), and plotting of weekly averages across time. MAIN OUTCOME MEASURES: Weekly motor and cognitive functional status. RESULTS: With the exception of cognitive functioning for persons with SCI, LOS was related to initial functional status, with patients with greater disability having longer LOS (eg, initial motor status for persons with stroke was 48.3 for those with a 2-week stay, 36.8 for a 6-week stay, with the averages between decreasing monotonically). With the exception of cognitive gains for person with TBIs, the amount of functional gain during rehabilitation was essentially the same for all LOS groups (eg, the overall average total motor gain for persons with SCI is 22.3, with no patterns of increase or decrease across LOS groups); however, the rate of improvement in motor (but not cognitive) functioning differed across LOS groups, with patients with shorter stays having the greater rates of improvement (eg, the overall average weekly motor gain for persons with SCI was 3.6, with the averages by LOS group monotonically decreasing from 6.4 for those with 4-week stays to 2.7 for those with 9-week stays). CONCLUSIONS: When examined separately for persons grouped by LOS, functional status improved linearly during the rehabilitation stay, with differences in rate of improvement depending on initial functional status.     

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.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose: The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method: The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa = 0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results: The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions: A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

Outcome after traumatic brain injury: effects of aging on recovery

OBJECTIVE: To identify differences in outcome after traumatic brain injury (TBI) compared with orthopedic injuries as a function of age. DESIGN: Longitudinal data analyses from an inception cohort. SETTING: Outpatient rehabilitation program. PARTICIPANTS: Eighty-two orthopedic injury patients and 195 TBI patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent living, employment, and level of functioning 1 to 2 years after injury. RESULTS: Older patients and those with TBI were more likely to have increased dependence postinjury. Older TBI patients were more likely to have changes in employment status compared with orthopedic injury patients younger or TBI. The Mayo-Portland Adaptability Inventory and Disability Rating Scale were moderately predictive of level of functioning, return to employment, and independent living status 1 to 2 years postinjury. Injury severity was only mildly predictive of outcome. CONCLUSIONS: The effect of age on outcome affects recovery from neurologic injuries and, to a lesser extent, orthopedic injuries. Outcome after TBI is best predicted by patients' age and estimates of level of function at discharge. Findings suggest that older patients and those with TBI have a greater likelihood of becoming physically and financially dependent on others. Rehabilitation efforts should focus on maximizing levels of independence to limit financial and emotional costs to patients and their families.     

Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model

Purpose:?The purpose of this article is to critically review the literature to examine factors that are most consistently related to employment outcome following traumatic brain injury (TBI), with a particular focus on metacognitive skills. It also aims to develop a conceptual model of factors related to employment outcome.

Method:?The first stage of the review considered 85 studies published between 1980 and December 2003 which investigated factors associated with employment outcome following TBI. English-language studies were identified through searches of Medline and PsycINFO, as well as manual searches of journals and reference lists. The studies were evaluated and rated by two independent raters (Kappa?=?0.835) according to the quality of their methodology based upon nine criteria. Fifty studies met the criteria for inclusion in the second stage of the review, which examined the relationship between a broad range of variables and employment outcome.

Results:?The factors most consistently associated with employment outcome included pre-injury occupational status, functional status at discharge, global cognitive functioning, perceptual ability, executive functioning, involvement in vocational rehabilitation services and emotional status.

Conclusions:?A conceptual model is presented which emphasises the importance of metacognitive, emotional and social environment factors for improving employment outcome.     

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.     

Early versus later admission to postacute rehabilitation: impact on functional outcome after traumatic brain injury

OBJECTIVE: To examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI). DESIGN: Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design. SETTING: Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital. PARTICIPANTS: Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29). INTERVENTIONS: Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community. MAIN OUTCOME MEASURES: Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire. RESULTS: All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge. CONCLUSIONS: The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.     

Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes

Macciocchi S, Seel RT, Warshowsky A, Thompson N, Barlow K. Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes.ObjectiveTo determine the impact of co-occurring traumatic brain injury (TBI) on functional motor outcome and cognition during acute spinal cord injury (SCI) rehabilitation.DesignProspective, longitudinal cohort.SettingSingle-center National Institute of Disability and Rehabilitation Research SCI Model System.ParticipantsPersons aged 16 to 59 years (N=189) admitted for acute SCI rehabilitation during the 18-month recruitment window who met inclusion criteria.InterventionsNot applicable.Main Outcome MeasuresFIM Motor Scale (Rasch transformed) and acute rehabilitation length of stay (LOS).ResultsIn the tetraplegia sample, co-occurring TBI was not related to FIM Motor Scale scores or acute rehabilitation LOS despite having negative impacts on memory and problem solving. Persons with paraplegia who sustained co-occurring severe TBI had lower admission and discharge FIM Motor Scale scores and longer acute rehabilitation LOS than did persons with paraplegia and either no TBI or mild TBI. Persons with paraplegia and severe TBI had lower functional comprehension, problem solving, and memory and impairments on tests of processing speed compared with persons with paraplegia and no TBI, mild TBI, and moderate TBI. Persons with paraplegia and co-occurring mild and moderate TBI had equivalent acute rehabilitation motor outcomes and cognitive functioning compared with persons with paraplegia and no TBI.ConclusionsThis study provides evidence that persons aged 16 to 59 years with paraplegia and co-occurring severe TBI had worse motor outcomes and longer acute rehabilitation LOS than did persons with paraplegia and no TBI. Impairments in processing speed, comprehension, memory, and problem solving may explain suboptimal motor skill acquisition. Research with larger samples is required to determine whether mild and moderate TBI impact acute rehabilitation motor outcomes and LOS.     

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.     

Emotional and behavioral adjustment after traumatic brain injury.

OBJECTIVES: To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. DESIGN: Longitudinal evaluation of adjustment from 1 month to 1 year after injury. SETTING: Level I trauma center at a university hospital. PATIENTS: One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. MAIN OUTCOME MEASURES: Katz Adjustment Scale (KAS). RESULTS: The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. CONCLUSIONS: These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.     

Severity of pediatric traumatic brain injury and early neurobehavioral outcome: a cohort study.

Traumatic brain injury (TBI) is a major cause of pediatric disability. Its neurobehavioral sequelae can often be difficult to distinguish from premorbid problems. To establish the early neurobehavioral consequences of TBI, we compared a cohort of brain injured children with controls, individually matched on premorbid characteristics. Ninety-eight children, aged 6 to 15 years, with mild, moderate, and severe closed head injuries, were consecutively identified on presentation to two regional medical centers. Individually selected controls were matched for age, gender, school grade, behavior, and academic performance. Intellectual, neuropsychologic, and academic assessments were undertaken 3 weeks after full orientation was achieved. No significant case-control differences were found on 20 variables measuring premorbid status. The pattern of decline in performance with increasing severity of brain injury was consistent for measures assessing intelligence, memory, speeded motor performance, adaptive problem solving, and academic performance. Moderately and severely injured patients performed at normal levels in reference to standardized intellectual norms, but they showed impairment when compared with their matched controls. The impairments uncovered in this study place moderately and severely brain injured children at risk for problems in the acquisition of academic skills and higher-order cognitive abilities.     

Recovery from diffuse traumatic brain injury in Johannesburg: a concurrent prospective study.

Three hundred and twenty-six persons with light, moderate, or severe diffuse traumatic brain injury (TBI) were assessed during initial hospitalization in Johannesburg. One hundred and forty-four were followed up at approximately six months, 83 at 12 months, and 71 at 24 months posttrauma. The sample attrition rate was high. When patients could not be found, data were obtained from their caregivers. Recovery was measured in five different areas of functioning: family relationships, psychologic problems, activities of daily living (ADL), employment status, and physical status. Psychologic problems and family relationships worsened with time, but proficiency in ADL improved; physical and employment status remained relatively stable during the survey period. Severity of injury was significantly correlated with outcome in each functional area at some point in the follow-up period. Discrepancies between patients' and caregivers' perceptions of outcome were noted, particularly in the area of psychologic functioning. Caregivers tended to rate the recovery made by the patient as better than the outcome patients perceived themselves to have made. These differences in perception diminished with time. The multifactorial nature of recovery after TBI is indicated by the improvements seen in some functional areas and the worsening of outcome in other areas. These findings suggest that rehabilitation programs for persons with TBI should (1) include caregivers, (2) focus on the adjustment of both parties to their new circumstances, and (3) facilitate a convergence in their perceptions. Adequately defining recovery is a first step to estimating the prevalence of TBI, but necessitates further work. Epidemiology awaits a better understanding of the recovery process after TBI.