Journal of Head Trauma Rehabilitation最新文献

Objective: To examine the relationship between neighborhood disadvantage and severity of vestibular, sensory, mood-behavioral, and cognitive neurobehavioral symptoms among Veterans with a mild traumatic brain injury (mTBI); and whether Veterans in underrepresented racial/ethnic groups with high neighborhood disadvantage experience the most severe symptoms.

Setting: Outpatient Veterans Health Administration (VHA).

Participants: Veterans with the following data available in the electronic health record (2014-2020): (1) clinician-confirmed mTBI and complete neurobehavioral symptom inventory (NSI) as part of their comprehensive traumatic brain injury evaluation (CTBIE) and (2) area deprivation index (ADI) scores assessing neighborhood disadvantage from the same quarter as their CTBIE.

Design: Retrospective cohort study. Latent variable regression was used to examine unique and interactive relationships between neighborhood disadvantage, race/ethnicity, and neurobehavioral symptoms.

Main measures: NSI and ADI national percentile rank.

Results: The study included 58 698 eligible Veterans. Relative to Veterans in the first quintile of ADI national percentile rank, representing those with the least neighborhood disadvantage, Veterans in the ADI quintiles indicating greater neighborhood disadvantage reported more severe vestibular, sensory, mood-behavioral, and cognitive symptoms. The strongest associations between neighborhood disadvantage and neurobehavioral symptoms were observed within the sensory (β = 0.07-0.16) and mood-behavioral domains (β = 0.06-0.15). Statistical interactions indicated that the association between underrepresented racial/ethnic group status (vs. identifying as white, non-Hispanic) and the severity of neurobehavioral symptoms did not differ among those with severe neighborhood disadvantage versus those without.

Conclusion: Veterans with mTBI living in more disadvantaged neighborhoods reported more severe neurobehavioral symptoms relative to those in the most advantaged neighborhoods, with the strongest relationships detected within the sensory and mood-behavioral domains. While neighborhood disadvantage and underrepresented race/ethnicity were both independently associated with symptoms, these factors did not interact to produce more severe symptoms. Findings suggest that addressing factors driving socioeconomic disadvantage may assist in mitigating symptoms in this population.

Objective: To estimate the relative causal influence of physical and mental health on pain in persons with traumatic brain injury (TBI) within the year following injury.

Setting: Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) was a multicenter study that collected data from 18 level 1 trauma centers around the United States.

Participants: TRACK-TBI recruited adults who experienced an acute TBI. For this secondary analysis, participants were included if they endorsed pain during at least 1 follow-up within 1 year post-TBI.

Design: Secondary analysis using structural equation modeling of the longitudinal TRACK-TBI dataset of an inception cohort.

Interventions: None.

Main outcomes and measures: The primary outcomes are pain, physical health, and mental health. Pain was measured by averaging the T-scores of the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity and Pain Interference scales. Physical and mental health were measured with the raw component scores (physical component score and mental component score, respectively) on the Short Form Health Survey.

Results: Eighty-nine percent of the TRACK-TBI cohort (n = 2022) reported pain throughout 1 year postinjury. This sample (n = 1796) was primarily white (77%) men (67%) in their early forties with mild (87%) closed head injuries (99%) related to motor or road vehicle accidents (57%). Based on the final trimmed model, there was a stronger dominance of pain on physical and mental health than physical and mental health on pain. Thus, pain is a bigger driver of physical and mental health than vice versa.

Conclusions: Persistent pain is highly prevalent post-TBI and is a bigger driver of physical and mental health 1 year post-TBI than the other way round. Future research should aim to better understand the causes of pain post-TBI to inform what treatments are most effective at reducing pain intensity and interference post-TBI.

Objective: This study aimed to assess the prognostic value of various frailty assessment tools in predicting 30-day mortality and Glasgow outcome scale (GOS) at discharge in elderly patients with traumatic brain injury (TBI). Additionally, the study evaluated the role of muscularity as surrogate for frailty in the context of TBI.

Setting: Data were collected from patients treated as inpatients in a single hospital.

Participants: All patients aged 60 years or older who were admitted for TBI between 1/2010 and 12/2020.

Design: A single-center study, with retrospective analysis of clinical notes and computed tomography (CT) imaging at admission.

Mean measures: Assessment of frailty by different frailty grading scales, comorbidities by the Charlson Comorbidity Index (CCI), assessment of muscularity by muscle area measurements and their association with outcome of TBI.

Results: A total of 1104 patients with a median age of 78 years (IQR 72-84) were identified. The overall mortality rate was 12.9% (n = 137). Multivariate regression models identified frailty measured by the Clinical Frailty Scale (CFS) (P < .0001) as predictive variable for short-term mortality and the CCI as predictive variable for GOS at discharge (P = .009); muscle area measurements as surrogate markers of sarcopenia were not associated with outcome in our cohort. Implementing frailty as measured by CFS and CCI into prognostic models for short-term mortality increased their predictive power (increase of area under the ROC curve from 0.897 to 0.919).

Conclusions: Geriatric-specific models are necessary for a more accurate prognosis estimation of elderly patients with TBI. Our findings suggest that frailty measured by CFS and assessment of comorbidities by CCI adds prognostic value, while muscularity at various locations (as assessed in CT imaging) had no effect on 30-day mortality after TBI.

Objective: To test cross-lagged associations among sleep, headache, and pain in pediatric mild traumatic brain injury (mTBI).

Setting, participants, design: Children and adolescents aged 8.0 to 16.9 years who sustained a mTBI and presented to 1 of 5 pediatric emergency departments across Canada completed assessments at 1-week, 3 months, and 6 months post-injury as part of a larger prospective cohort study.

Main measures: Sleep disturbance was measured using 7 sleep items from the Child Behaviour Checklist. Sleep duration was measured using average weekday and weekend sleep from the Healthy Lifestyle Behaviours Questionnaire. Pain intensity was measured using an 11-point numerical rating scale. Headache severity and associated functional impairment were measured using the Headache Impact Test and 1 item from the Health and Behaviour Inventory. Analyses included trivariate-indicator random-intercept cross-lagged panel models.

Results: Of 633 recruited children, 563 were included in the current study. Headache showed significant within-person, bidirectional, cross-lagged associations with sleep disturbance and duration, as well as with pain intensity. More specifically, worse headache predicted greater sleep disturbance (1-week to 3 months and 3 months to 6 months: Bs = .47, Ps ≤ .013) and shorter sleep duration (1-week to 3 months: B = -.21, P = .006), while greater sleep disturbance predicted worse headache (1-week to 3 months: B = .08, P = .001). Worse headache also predicted higher pain intensity (1-week to 3 months & 3 months to 6 months: Bs ≥ 1.27, P s < .001), while higher pain intensity predicted worse headache (3 months to 6 months: Bs ≥ .03, Ps ≤ .042). No cross-lagged associations involving sleep disturbance or duration with pain intensity were significant.

Conclusions: Significant bi-directional, cross-lagged associations exist between headache and both sleep and pain. The findings suggest that early intervention for headaches may help prevent later sleep disturbance and pain after pediatric mTBI.

Objectives: (1) To evaluate the implementation of Australia's first occupational therapy-led concussion clinic model into usual practice by examining acceptability and fidelity among clinicians and service users, and (2) to explore the feasibility of embedding outcome measures into the service to facilitate longer-term clinic evaluation.

Setting and participants: A large tertiary trauma hospital service in Melbourne, Australia. Participants were patients referred to the concussion clinic and occupational therapists working in the service.

Design: Prospective, single-site, mixed methods design.

Main measures: Acceptability outcomes were evaluated using clinician interviews and the Client Satisfaction Questionnaire-8. Clinic fidelity was assessed by service usage data. Long-term patient outcomes assessed concussion (Rivermead Post-Concussive Questionnaire), mood symptoms (Patient Health Questionnaire-9), and participation in activities of daily living (Community Integration Questionnaire-Revised).

Results: Over 18 months, 73% (n = 177) of patients were referred to the clinic, and 75% attended. Adherence to protocol was achieved; however, the completion rate of post-treatment measures was low. Almost half of the patients required specialist referrals beyond the clinic model for persistent symptoms. The interviewed occupational therapists (n = 6) viewed the clinic as a "safety net for patients," believed they were "learning as we go," recognized that the "clinic had potential to grow," but admitted, "we could be doing more." High attendance rates and patient satisfaction further supported clinic acceptance at an end-user level.

Conclusion: An occupational therapy-led concussion clinic is accepted by patients and clinicians to capture the immediate needs of people with concussions after discharge. However, coordinated pathways to multidisciplinary care are needed to address the long-term needs of people with persistent concussion symptoms and problems returning to daily activities.

Background: In pediatric mild traumatic brain injury (mTBI), high rates of abnormalities are observed in vestibulo-ocular reflex (VOR) and oculomotor (OM) function, but there is a lack of understanding of how these impairments may affect daily functioning.

Objectives: To determine the extent to which clinician-administered measures of VOR and OM function are associated with patient-reported levels of activity limitations and participation restriction in children and adolescents within 31 days post-mTBI.

Design: Cross-sectional design.

Setting: Tertiary care pediatric hospital.

Participants: Participants with mTBI aged 7 to 17.99 years.

Procedures: Participants were assessed on a battery of VOR and OM tests within 31 days of injury.

Outcome measures: The Dizziness Handicap Inventory (DHI) and Cardiff Visual Ability Questionnaire (CVAQ) measured patient-reported dizziness and visual disability. The vestibular/ocular motor screening tool (VOMS), Head Thrust Test, computerized Dynamic Visual Acuity (DVA) Test, and video Head Impulse Test were administered to assess VOR and OM function.

Analysis: Linear regression examined the associations between clinician-administered measures of VOR and OM function and patient-reported functional outcomes.

Results: The sample consisted of 100 youth (54.4% female; mean age 13.92 [2.63]; mean time since injury: 18.26 [6.16] days). Associations were found between (1) DHI score and age (1.773 [0.473-3.073], P = .01), VOR symptom provocation (18.499 [11.312-25.686], P ≤ .001), and DVA (-29.433 [-59.206 to -2.60], P = .03); and (2) CVAQ score and version symptom provocation (0.796 [0.185-1.406], P = .01). High abnormal proportions (up to 56.7%) were found in VOMS performance.

Discussion: The symptom provocation induced by VOR and OM tasks was associated with patient-reported dizziness and visual disability outcomes, highlighting the detrimental impact of symptoms on daily functioning.

Implications: The findings of this study will assist clinicians when interpreting patient-reported measures of activity limitation and participation restriction.

Objectives: This study aimed to identify outcome clusters among individuals with traumatic brain injury (TBI), 6 months to 10 years post-injury, in an Australian rehabilitation sample, and determine whether scores on 12 dimensions, combined with demographic and injury severity variables, could predict outcome cluster membership 1 to 3 years post-injury.

Setting: Rehabilitation hospital.

Participants: A total of 467 individuals with TBI, aged 17 to 87 (M = 44.2 years), 70% male, with mean post-traumatic amnesia 24 days (range 0.5-455 days), were assessed a mean of 3.4 years post-injury (range 0.5-10 years). A subgroup of 138 participants was also evaluated as rehabilitation inpatients and followed up 1 year post-injury.

Design: Prospective observational study.

Main measures: TBI Quality of Life subscales (Upper Extremity, Pain Interference, Headache Pain, Anxiety, Resilience, Emotional and Behavioral Dyscontrol, General Cognitive Concerns, Independence, and Economic Quality of Life Scale), Neurobehavioral Symptom Inventory, Family Assessment Device General Functioning Scale, Wechsler Adult Intelligence Scale-IV Letter-Number-Sequencing and Coding, Rey Auditory Verbal Learning Test, Trail Making Test Part A, Verbal Fluency Test, Word Memory Test, Participation Assessment with Recombined Tools-Objective, and Glasgow Outcome Scale-Extended.

Results: K-means cluster analysis revealed 5 clusters across 12 dimensions: Good Outcome, High Cognition, Poor Cognition, Poor Outcome, and Poor Adjustment, aligning with Sherer and colleagues' clusters. Inpatient assessments (n = 138) identified profiles predictive of outcome group membership. Participants with Good Outcomes exhibited lower anxiety and higher independence, self-esteem, and resilience, despite some cognitive deficits. High Cognition correlated with robust Economic and Family Support. Poor Cognition aligned with impaired cognitive function but positive psychosocial ratings suggest limited self-awareness. Poor Outcome featured low initial cognitive scores and poor psychosocial adjustment. Poor Adjustment participants, without inpatient cognitive impairments, reported persistent pain, physical symptoms, and emotional distress.

Conclusions: Findings support the evaluation of cognitive and psychosocial factors during rehabilitation to predict outcomes with potential to inform rehabilitative interventions to optimize outcomes.

Objective: To examine whether neurobehavioral symptoms mediate the relationship between comorbid mental health conditions (major depressive disorder [MDD] and/or posttraumatic stress disorder [PTSD]) and participation restriction among Veterans with mild traumatic brain injury (mTBI).

Setting: Veterans Health Administration (VHA).

Participants: National sample of Veterans with mTBI who received VHA outpatient care between 2012 and 2020.

Design: Secondary data analysis of VHA clinical data. We specified a latent variable path model to estimate relationships between: (1) comorbid mental health conditions and 3 latent indicators of neurobehavioral symptoms (vestibular-sensory; mood-behavioral; cognitive); (2) latent indicators of neurobehavioral symptoms and 2 latent indicators of participation restriction (social and community participation; productivity); and (3) comorbid mental health conditions and participation restriction.

Main measures: International Classification of Diseases codes, Neurobehavioral Symptom Inventory, and Mayo-Portland Adaptability Inventory Participation Index to measure mental health conditions, neurobehavioral symptoms, and participation restrictions, respectively.

Results: Indirect effect estimates indicated that comorbid MDD and/or PTSD was associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = .22-.33; 99% CI 0.18-0.4; small to medium effect) and cognitive symptoms (β = .08-.13; 99% CI 0.05-0.18; small effect), and with greater productivity restrictions, as mediated by vestibular-sensory (β = .06-.11; 99% CI 0.04-0.15; small effect) and cognitive symptoms (β = .08-.13; 99% CI 0.05-0.18; small effect). Direct effect estimates indicated that comorbid MDD and/or PTSD was associated with greater challenges with both social and community participation (β = .19-.40; 99% CI 0.12-0.49; small to medium effect) and productivity (β = .08-.44; 99% CI -0.02 to 0.55; small to medium effect).

Conclusion: Neurobehavioral symptoms partially mediated the impact of MDD and/or PTSD on participation restrictions among Veterans with mTBI. These findings advance the understanding of explanatory mechanisms underlying participation challenges among Veterans with comorbid mTBI and mental health challenges, thereby informing the development of tailored intervention strategies.

Objective: To investigate the incidence of early/unplanned (E/U) separations following mild traumatic brain injury (mTBI) and assess whether sex impacts the hazard of separation.

Setting: Military Health System (MHS).

Participants: Active duty service members (N = 75,730) with an initial mTBI diagnosis in military records between January 2011 and January 2018.

Design: Retrospective cohort study of electronic health records in the MHS. Cause-specific Cox proportional hazards models were used with sex at birth as the primary predictor.

Main measures: Early/unplanned (E/U) separation, defined as military separation attributed to disability, misconduct, poor performance, death, or other medical circumstances, within 2 years following the initial mTBI.

Results: Incidence of E/U separation within 2 years following mTBI was 13.7% (11.0% in women and 14.2% in men). Disability and misconduct separations were most common. Female service members had lower adjusted hazards for any E/U separation (Hazard Ratio [HR] = 0.65; 95% Confidence Interval [CI]: 0.61,0.69), disability separation (HR = 0.71; 95% CI: 0.65, 0.78), misconduct separation (HR = 0.40; 95% CI: 0.36, 0.45), and poor performance separation (HR = 0.84; 95% CI: 0.72, 0.99), compared to males, but had higher adjusted hazards for separations due to other medical circumstances (HR = 1.24; 95% CI: 1.04, 1.48).

Conclusion: Male and female service members had different hazards of E/U separation following mTBI. Separating early may increase the risk of adverse health and socioeconomic outcomes, so additional research is needed on why these separations occur and why they may be impacting men and women differently.

Objective: This study assessed (1) the feasibility and usability of traumatic brain injury (TBI) assessment using the Ohio State University TBI Identification Method (OSU-TBI-ID) in a sample of English and Spanish-speaking refugees and asylum seekers (hereafter refugees), and (2) the prevalence and characteristics of TBI in this population.

Setting and participants: Refugees seeking care from Massachusetts General Hospital (MGH) Asylum Clinic, the MGH Chelsea HealthCare Center, and other asylum programs in the Greater Boston Area.

Design and main measures: Bilingual clinical research coordinators screened 158 English and Spanish-speaking refugees using the OSU-TBI-ID. A "positive" screen for TBI was made if a participant reported loss of consciousness (LOC) or being dazed or confused following a head injury, with determinations of mild, moderate, and severe TBI based on established metrics of TBI severity using duration of LOC. We conducted descriptive statistics of the sample demographics and screening outcomes, including group comparisons between those with and without TBI and associated demographic characteristics.

Results: The mean age was 36.8 years (SD: 9.1), with participants predominantly from Latin America and the Caribbean (51%), followed by Sub-Saharan Africa (35%). Less than half (43%) identified as men. The majority (59%) screened positive for having experienced at least 1 TBI in their lifetime. Among those with a TBI history, nearly three-quarters (73%) had a mild TBI, and about a third (38%) had sustained a moderate-to-severe TBI. A majority (56%) had more than 1 TBI and about 40% had sustained a childhood TBI. The most common mechanisms of injury were interpersonal assault (55%) and blunt trauma by an object (46%). There were no significant statistical differences in demographics and TBI characteristics.

Conclusion: Our findings demonstrate the feasibility and usability of the OSU-TBI-ID in a sample of refugees. We call for greater and improved detection of TBI among refugees to ensure they receive the optimal care they need.