Caregivers' Well-Being After Traumatic Brain Injury: A Multicenter Prospective Investigation

Kreutzer JS, Rapport LJ, Marwitz JH, Harrison-Felix C, Hart T, Glenn M, Hammond F. Caregivers' well-being after traumatic brain injury: a multicenter prospective investigation.

Objective

To describe frequency and magnitude of caregivers' emotional distress and life satisfaction using standardized assessment procedures; compare distress levels among spouses, parents, and other caregivers; and identify risk factors.

Design

Prospective collaborative cohort study.

Setting

Six Traumatic Brain Injury Model System Centers providing neurotrauma care, rehabilitation, and outpatient follow-up.

Participants

Caregivers (N=273) of patients who were 1, 2, or 5 years postinjury.

Interventions

Acute neurotrauma care, inpatient interdisciplinary brain injury rehabilitation, and postacute services.

Main Outcome Measure

Brief Symptom Inventory-18 Depression, Anxiety, and Somatic dimensions.

Results

Levels of Depression, Anxiety, and Somatic symptoms were equally prevalent, with 1 in 5 caregivers scoring above the cutoff in each area. The proportion of participants with 1, 2, and 3 elevations was 17.9%, 5.5%, and 10.6%, respectively. Conversely, approximately two thirds (65.9%) had no scores exceeding cutoffs. Distress levels among spouses, parents, and other caregivers were comparable. Higher caregiver distress was associated with caring for survivors who had worse functional status, received more supervision, were less satisfied with life, and used alcohol excessively.

Conclusions

Depression, Anxiety, and Somatic symptoms are common among caregivers. Findings substantiate the importance of clinical care systems addressing the needs of caregivers in the long term as well as survivors.     

Incidence of Gait Abnormalities After Traumatic Brain Injury

Williams G, Morris ME, Schache A, McCrory PR. Incidence of gait abnormalities after traumatic brain injury.

Objective

To identify the most common gait abnormalities presenting after traumatic brain injury (TBI) and quantify their incidence rate.

Design

Case series.

Setting

Biomechanics laboratory.

Participants

A convenience sample of 41 people with TBI receiving therapy for gait abnormalities, and a sample of 25 healthy controls.

Intervention

Three-dimensional gait analysis.

Main Outcome Measures

Spatiotemporal, kinematic, and kinetic data at a self-selected walking speed.

Results

People with TBI walked with a significantly slower speed than matched healthy controls. There was a significant difference between groups for cadence, step length, stance time on the affected leg, double support phase, and width of base of support. The most frequently observed biomechanical abnormality was excessive knee flexion at initial foot contact. Other significant gait abnormalities were increased trunk anterior/posterior amplitude of movement, increased anterior pelvic tilt, increased peak pelvic obliquity, reduced peak knee flexion at toe-off, and increased lateral center of mass displacement. Ankle equinovarus at foot-contact occurred infrequently.

Conclusions

People with TBI were found to have multijoint gait abnormalities. Many of these abnormalities have not been previously reported in this population.     

Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury

Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury.

Objectives

To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Sixteen TBI Model System Centers.

Participants

Blacks (n=615) and whites (n=1407) with moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measure

Employment status dichotomized as competitively employed versus not competitively employed.

Results

After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race (P≤.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites (P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury.

Conclusions

Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.     

Comorbidity of Pain and Depression Among Persons With Traumatic Brain Injury

Objective

To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI).

Design

Longitudinal survey design with 1-year follow-up.

Setting

Inpatient rehabilitation and the community.

Participants

Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥4 were classified as having pain, and participants with PHQ-9 scores ≥10 were classified as depressed.

Results

Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001).

Conclusions

Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time.     

Functional Recovery After Severe Traumatic Brain Injury: An Individual Growth Curve Approach

Objective

To examine person, injury, and treatment characteristics associated with recovery trajectories of people with severe traumatic brain injury (TBI) during inpatient rehabilitation.

Design

Observational prospective longitudinal study.

Setting

TBI rehabilitation units.

Participants

Adults (N=206) with severe nonpenetrating TBI admitted directly to inpatient rehabilitation from acute care. Participants were excluded for prior disability and intentional etiology of injury.

Interventions

Naturally occurring treatments delivered within comprehensive multidisciplinary teams were recorded daily in 15-minute units provided to patients and family members, separately.

Main Outcome Measures

Motor and cognitive FIM were measured on admission, discharge, and every 2 weeks in between and were analyzed with individual growth curve methodology.

Results

Inpatient recovery was best modeled with linear, cubic, and quadratic components: relatively steep recovery was followed by deceleration of improvement, which attenuated prior to discharge. Slower recovery was associated with older age, longer coma, and interruptions to rehabilitation. Patients admitted at lower functional levels received more treatment, and more treatment was associated with slower recovery, presumably because treatment was allocated according to need. Therefore, effects of treatment on outcome could not be disentangled from effects of case mix factors.

Conclusions

FIM gain during inpatient recovery from severe TBI is not a linear process. In observational studies, the specific effects of treatment on rehabilitation outcomes are difficult to separate from case mix factors that are associated with both outcome and allocation of treatment.     

Prior History of Traumatic Brain Injury Among Persons in the Traumatic Brain Injury Model Systems National Database

Objective

To determine the association between demographic, psychosocial, and injury-related characteristics and traumatic brain injury (TBI) occurring prior to a moderate or severe TBI requiring rehabilitation.

Design

Secondary data analysis.

Setting

TBI Model System inpatient rehabilitation facilities.

Participants

Persons (N=4464) 1, 2, 5, 10, 15, or 20 years after TBI resulting in participation in the TBI Model System National Database.

Interventions

Not applicable.

Main Outcome Measures

History of TBI prior to the TBI Model System Index injury, pre-Index injury demographic and behavioral characteristics, Index injury characteristics, post-Index injury behavioral health and global outcome.

Results

Twenty percent of the cohort experienced TBIs preceding the TBI Model System Index injury—80% of these were mild and 40% occurred before age 16. Pre- and post-Index injury behavioral issues, especially substance abuse, were highly associated with having had a prior TBI. Greater severity of the pre-Index injury as well as occurrence before age 6 often showed stronger associations. Unexpectedly, pre-Index TBI was associated with less severe Index injuries and better functioning on admission and discharge from rehabilitation.

Conclusions

Findings suggest that earlier life TBI may have important implications for rehabilitation after subsequent TBI, especially for anticipating behavioral health issues in the chronic stage of recovery. Results provide additional evidence for the potential consequences of early life TBI, even if mild.     

Sensitivity and Specificity of the Beck Depression Inventory-II in Persons With Traumatic Brain Injury

Homaifar BY, Brenner LA, Gutierrez PM, Harwood JF, Thompson C, Filley CM, Kelly JP, Adler LE. Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury.

Objectives

Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives.

Design

This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI.

Setting

This study was completed at a Veterans Affairs (VA) Medical Center.

Participants

Participants were veterans eligible to receive VA health care services.

Interventions

Not applicable.

Main Outcome Measures

Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV).

Results

We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%).

Conclusions

Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.     

Utilization of Behavioral Therapy Services Long-Term After Traumatic Brain Injury in Young Children

Objective

To examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group.

Design

Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury.

Setting

Children's hospitals and a general hospital.

Participants

Participants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.

Interventions

Not applicable.

Main Outcome Measures

Parents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit.

Results

Children with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups.

Conclusions

The results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.     

A Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain Injury

Cicerone KD, Mott T, Azulay J, Sharlow-Galella MA, Ellmo WJ, Paradise S, Friel JC. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.

Objective

To evaluate the effectiveness of comprehensive, holistic neuropsychologic (NP) rehabilitation compared with standard, multidisciplinary rehabilitation for people with traumatic brain injury (TBI).

Design

Randomized practical controlled trial.

Setting

Postacute brain injury rehabilitation center within a suburban rehabilitation hospital.

Participants

Participants with TBI were recruited from clinical referrals and referrals from the community. Sixty-eight participants who met inclusion criteria were randomly allocated to treatment conditions. Most participants (88%) had sustained moderate or severe TBI, and greater than half (57%) were more than 1 year postinjury at the beginning of treatment.

Interventions

Treatment was conducted 15 hours per week for 16 weeks. Standard neurorehabilitation consisted primarily of individual, discipline specific therapies (n=34). Intensive cognitive rehabilitation emphasized the integration of cognitive, interpersonal, and functional interventions within a therapeutic environment (n=34).

Main Outcome Measures

Primary outcomes were the Community Integration Questionnaire (CIQ) and Perceived Quality of Life scale (PQOL). Secondary outcomes included NP functioning, perceived self-efficacy, and community-based employment.

Results

NP functioning improved in both conditions. Intensive cognitive rehabilitation participants showed greater improvements on the CIQ (effect size [ES]=0.59) and PQOL (ES=0.30) as well as improved self-efficacy for the management of symptoms (ES=0.26) compared with standard neurorehabilitation treatment. These gains were maintained at the 6-month follow-up. Standard neurorehabilitation participants showed improved productivity at the 6-month follow-up associated with the need for continued rehabilitation.

Conclusions

Improvements seen after intensive cognitive rehabilitation may be related to interventions directed at the self-regulation of cognitive and emotional processes and the integrated treatment of cognitive, interpersonal, and functional skills. The results show the effectiveness of comprehensive holistic NP rehabilitation for improving community functioning and quality of life after TBI compared with standard rehabilitation.