Journal of Head Trauma Rehabilitation最新文献

Objective: To assess the impact of probable deployment traumatic brain injury (TBI) history on post-9/11 US veterans' participation in productive activities-including employment, caregiving, volunteering, and education-after military service.

Methods: This secondary cross-sectional analysis of the Veterans Metrics Initiative (TVMI) study examined productive activities among 8946 veterans who transitioned from service in 2016 and completed the TVMI survey. Associations between probable deployment TBI and activity engagement were analyzed using bivariate analysis and multinomial logistic regression. Probable deployment TBI, the independent variable, was defined as a head injury with loss or alteration of consciousness. The dependent variable was engagement in productive activities, categorized as neither paid nor unpaid labor (reference), paid labor only, paid and unpaid labor, and unpaid labor only. Covariates included demographic characteristics, self-reported premilitary TBI, and a positive screen for probable post-traumatic stress disorder (PTSD) identified using the PC-PTSD-5 screening tool.

Results: Veterans with probable deployment TBI were significantly less likely to engage in paid labor only (risk ratio [RR] = 0.66, 95% confidence interval [CI]: 0.55-0.79, P < .001) or paid and unpaid labor (RR = 0.79, 95% CI: 0.65-0.96, P = .023) compared to those without TBI. Conversely, they were more likely to engage in unpaid labor only (RR = 1.23, 95% CI: 1.02-1.48, P = .024). These associations remained after adjusting for covariates described above.

Conclusions: Productive activity engagement differed between veterans with and without probable deployment TBI. Veterans with probable deployment TBI were less likely to participate in paid labor and more likely to engage in unpaid or no labor. Additional support may be needed to facilitate their transition into the civilian workforce.

Objective: To explore if the STEP-Home (SH) group workshop improves neurobehavioral symptoms, civilian readjustment, anger control, and frontal system function in post-9/11 Veterans with and without a TBI. This is a secondary analysis from a 2-arm randomized controlled trial (RCT).

Participants: One hundred and ninety-five male and female post-9/11 Veterans participated in a multisite RCT of SH versus Present Centered Group Therapy; a subset of 66 who received the SH intervention and completed all assessments were selected for this analysis. Participants were grouped based on TBI diagnosis. Almost half had a history of TBI (TBI+ n = 28; 42.4%; mean age 38.6 ± 9.1 years) whereas 38 had no history of TBI (TBI- mean age 41.0 ± 12.2 years).

Setting: VA Healthcare System and telehealth.

Intervention: SH was a 12-week, 90 minute/week, transdiagnostic, skills-based group intervention focused on problem solving, emotion regulation, and anger control skill building.

Main measures: Outcomes were neurobehavioral symptoms, anger control, reintegration status, and frontal system function. Data were collected at pre-treatment (T1), post-treatment (T2), and at 12-week post-treatment follow-up (T3).

Results: Both groups (TBI+ and TBI-) showed significant improvements in neurobehavioral symptoms, reintegration status, and aspects of frontal system function. Anger control was only improved in the TBI+ group. Treatment benefits were maintained over time.

Conclusions: The STEP-Home intervention shows promise for improving persistent neurobehavioral symptoms in Veterans with and without a history of TBI. Treatment benefits were maintained over time in both groups. Veterans with a history of TBI showed significant improvement in anger control, which is critical to improving daily functional status after brain injury. SH offers an acceptable, transdiagnostic alternative treatment approach to improve functioning for Veterans with TBI and those at risk for TBI/brain injury due to military service.

Objective: To examine the relationship between injury context with psychiatric and cognitive outcomes among combat-exposed Veterans and Service Members with remote mild traumatic brain injury (mTBI).

Setting: Veterans and Service Members enrolled in the Long-Term Impact of Military-Relevant Injury Consortium (LIMBIC)-Chronic Effects of Neurotrauma Consortium (CENC).

Participants: LIMBIC-CENC-enrolled participants who had sustained an mTBI exclusively in combat zones (c-mTBI +; n = 314), mTBI sustained exclusively in non-combat settings (c-mTBI-; n = 526), or no history of mTBI (no TBI; n = 347). Inclusion criteria for this study included (1) availability of all mTBI injury-related characteristics, (2) completion of all psychiatric symptom measures, and (3) completion of all neuropsychological measures used for this study.

Design: Cross-sectional secondary analysis.

Main measures: Primary outcomes of interest included total scores on self-reported psychiatric symptom measures (post-traumatic stress, neurobehavioral, and cognitive concerns) and objective cognitive composite test scores (attention, learning, processing speed, executive function, and delayed recall). All analyses adjusted for age, gender, and education.

Results: Results of separate multivariate analyses of variance indicated that the c-mTBI+ group reported higher post-traumatic (ηP2 = .08) and neurobehavioral symptoms (ηP2 = .07), and cognitive concerns (ηP2 = .04) compared to the c-mTBI- and no TBI groups, whereas the c-mTBI- and no TBI groups did not differ except on cognitive concerns. Additionally, groups did not differ across cognitive composite performance except for significant though weak group differences on learning (ηP2 = .01), delayed recall (ηP2 = .03), and processing speed (ηP2 = .01). Separate hierarchical regression analyses indicated psychiatric symptom burden explained 7-18% of the total variance in cognitive composite performance as a function of mTBI group history (ps ≤ .002).

Conclusions: These findings build upon prior work showing that injury context - the context in which mTBI occurs - may play an important role in long-term psychiatric and cognitive outcomes.

Objective: To determine the incidence of exercise-induced symptom exacerbation and adverse events from cardiorespiratory fitness (CRF) and high-level mobility (HLM) exertional testing in the early subacute phase (≤3 months post-injury) following moderate-to-severe traumatic brain injury (TBI).

Setting: Inpatient TBI subacute rehabilitation unit.

Participants: One hundred fifty adults and adolescents ≥15 years with moderate-to-severe TBI completed a total of 205 exertional tests (83 participants completed CRF only, 12 HLM only, and 55 both CRF and HLM).

Design: Prospective observational cohort study. Consecutive admissions were screened for recruitment between August 2017 and August 2021. Symptom ratings were recorded pre- and post-CRF and HLM exertional testing on the Sports Concussion Assessment Tool symptom scale. A summed symptom severity score (SCAT-SS) was calculated with a ≥10-point increase classified as symptom exacerbation and a ≥10-point reduction classified as symptom improvement.

Main measures: SCAT symptom scale.

Results: One participant experienced a ≥10-point increase in SCAT-SS (ie, symptom exacerbation) post-CRF testing (1/138 = 0.7%, 95% confidence interval [CI] = 0.01%-4.0%) and 1 post-HLM testing (1/67 = 1.5%, 95% CI = 0.04%-8.0%). Sixteen of 138 (11.6%, 95% CI = 6.8%-18.1%) CRF tests resulted in a ≥10-point decrease in SCAT-SS (ie, symptom improvement). Nine of 67 (13.4%, 95% CI = 6.3%-24.0%) HLM tests resulted in a ≥10-point decrease in SCAT-SS. Participants were more likely to experience symptom improvement than symptom exacerbation for both CRF and HLM exertion (P ≤ .05). One adverse event, a fall, occurred during an HLM testing session.

Conclusions: CRF and HLM exertional testing in the early subacute phase of recovery following moderate-to-severe TBI appears to be safe, with low rates of symptom exacerbation and adverse events identified.

Objective: To characterize factors associated with death due to cardiovascular causes following complicated mild to severe traumatic brain injury (TBI).

Setting: Chart review or telephonic interviews.

Participants: Participants enrolled in the TBI Model Systems database.

Design: Retrospective.

Main measures: Primary cause of death due to cardiovascular causes coded with ICD-9 codes 390-459 or ICD-10 codes 100-199 (diseases of the circulatory system) on death certificates. A competing risk cause-specific Cox proportional hazards regression analysis was completed to identify demographic and injury-related factors associated with increased risk of cardiovascular-related mortality.

Results: Overall, 15,370 participants were included. Overall, 2,770 (18.0%) individuals died, of which 595 (21.5%) died due to cardiovascular-related causes. Those who died due to cardiovascular causes were older (hazard ratio [HR] 1.08, 95% 1.07-1.09, P <.001), more likely to be male (HR 1.84, 95% CI 1.50-2.26, P <.001), divorced (HR 1.63, 95% CI 1.20-2.23, P = .002), and had lower functional independence measure motor scores (HR 0.99, 95% CI 0.98-0.99, P <.001). Individuals who identified as Asian/Pacific Islander (HR 0.21, 95% CI 0.08-0.55, P = .002), were employed (HR 0.65, 95% CI 0.46-0.90, P = .010), had private insurance (HR 0.77, 95% CI 0.60-0.99, P = .043), and had post-traumatic amnesia (PTA) duration >30 days (HR 0.71, 95% CI 0.55-0.92, P = .010) were less likely to die due to cardiovascular causes. Alcohol or drug use and education level were not significantly associated with death due to cardiovascular causes.

Conclusion: Over 1 in 5 deaths following TBI were due to cardiovascular causes. Older age, male sex, being divorced, and having lower FIM motor scores are risk factors, whereas being employed, having private health insurance, and PTA >30 days are protective factors for cardiovascular mortality.

Objective: To identify the prevalence of incident traumatic brain injury with loss of consciousness (traumatic brain injury [TBI] with loss of consciousness [LOC]) among a cohort of individuals with preexisting disabilities. To examine age at first TBI with LOC and number of TBI with LOC. To identify whether TBI with LOC was associated with type of preexisting primary disability and age of disability onset. We also compared psychosocial function between those with and without TBI with LOC.

Setting: 2023/2024 National Survey on Health and Disability (NSHD).

Participants: Adults aged ≥18 years, living in the US, with self-reported preexisting disabilities. Our analyses included 235 participants who reported TBI with LOC after the onset of their primary disability, and 1211 participants who did not experience TBI with LOC.

Design: Cross-sectional observational online survey.

Main measures: NSHD survey and abbreviated Brain Injury Screening Questionnaire.

Results: A total of 235 individuals sustained TBI after disability onset. The average age of first TBI with LOC was 20.3 years, and 34.1% of participants incurred multiple TBIs with LOC. In fully adjusted models, relative to a primary physical/mobility disability, having a primary mental illness/psychiatric disability was associated with higher odds of incident TBI with LOC. Younger age at disability onset was associated with a 5% greater odds of reporting incident TBI with LOC. Finally, those with TBI with LOC were more likely to report poor physical and mental health days, and greater levels of loneliness, but did not have higher odds of unemployment compared to those without TBI.

Conclusion: TBI with LOC in those living with preexisting disability is common, associated with younger age at disability onset, greater likelihood of poor physical and mental health days, and greater loneliness. Screening for TBI in those living with all-cause disability is warranted, alongside care coordination to meet care needs of this vulnerable but historically overlooked group.

Objective: Our aim was to explore the length of stay (LOS) as a predictor of long-term mortality in patients surviving a traumatic brain injury (TBI). The objectives were to (1) establish TBI length of stay (LOS)-based groups empirically, (2) assess their accuracy in predicting death, and (3) compare the long-term risk of death between the LOS-based groups and non-TBI controls (Controls).

Participants: Patients (≥18.0) with TBIs in Denmark between 1994 and 2018 that survived beyond discharge were (1:5) age-matched with Controls.

Design: Nationwide cohort study. TBI patients and Controls were stratified according to age: 18.0-39.9, 40.0-69.9, and ≥70.0.

Main measures: Adjusted binomial regression was used to estimate odd ratios for mortality, and predictive accuracy was assessed using cross-validated area under the receiver operation curve (AUC) values. The Kaplan-Meier method and the adjusted binomial regression models were used to compare the all-cause mortality between LOS-based groups and Controls.

Results: Among 153 177 TBI survivors, LOS-based groupings showed modest stratification of mortality risk, particularly in those under 70.0 years. However, based on the AUC, they did not improve individual-level prediction of death once adjusted for key confounders. Compared with Controls, TBI survivors had persistently excess mortality risk of up to 20 years post-index across all age groups. In older adults, LOS was positively correlated with the number of new comorbidities detected during hospitalization, which likely contributed to the observation that TBI patients with short LOS had better survival than Controls in this age population (surveillance bias).

Conclusions: LOS-based groups did not predict individual-level risk of death in TBI survivors but offered some short-term risk stratification at a group-level. Its application to group-level mortality outcomes in older adults is complicated by surveillance bias. Persistent excess mortality across all age groups supports the need for long-term follow-up after TBI.

Objective: To examine the development of different dimensions of fatigue and subjective and objective measures of sleep in the first 18 months post moderate to severe traumatic brain injury (TBI), and explore the association with biological (processing speed), psychological (mood), and social (restrictions in participation) factors across time.

Participants: Forty-two participants with moderate-severe TBI (45 ± 16 years old, 33% female).

Design: Longitudinal multicenter observational cohort study with 4 measurements (3, 6, 12, and 18 months post-injury).

Main measures: Dimensions of fatigue (Fatigue Severity Scale, FSS; Dutch Multifactor Fatigue Scale, DMFS), subjective (Pittsburgh Sleep Quality Index, PSQI) and objective sleep (actigraphy), processing speed (Symbol Digit Modalities Task, SDMT), mood (Hospital Anxiety and Depression Scale, HADS), and restrictions in participation (Utrecht Scale for Evaluation and Rehabilitation-Participation, USER-P).

Results: Results showed reduced sleep quality (PSQI: poor sleep quality at 3 months 41%; 6 months 43%; 12 months 56%; 18 months 43%) and high levels of fatigue (FSS: severe fatigue at 3 months 41%; 6 months 38%; 12 months 33%; 18 months 34%) with no significant changes over time. Physical fatigue (DMFS: β = -0.11, P = .007) and total sleep time (β = -0.14, P = .015) decreased over time. More mood problems were associated with worse sleep quality (PSQI; β = 0.35, P = .021), shorter total sleep time (β = 0.14, P = .046), and higher levels of fatigue (FSS: β = 0.20, P = .036; DMFS-mental: β = 0.36, P = .028; DMFS-physical: β = 0.36, P = .029). Restrictions in participation were associated with fatigue but not with sleep.

Conclusions: High and stable levels of fatigue and poor sleep quality in the first 18 months following moderate-severe TBI were found. These symptoms were associated with mood problems. Assessment and treatment of fatigue and sleep problems should be included in clinical practice. In line with other studies, we suggest that mood interventions might aid the treatment for fatigue and sleep quality.

Objective: This study aims to validate an instrumented dual-task (DT) assessment procedure based on smartphone-embedded sensors. Data processing algorithms were developed to extract relevant features, and ice hockey players were evaluated.

Participants: In total, 114 Swiss elite ice hockey players.

Design: Experimental study.

Main measures: Participants performed DT tests regularly during the season and within the days following a diagnosed concussion. The DT test consisted of static balance and self-paced walking, combined with counting backward by 3. In total, 265 DT tests were performed, including 38 tests between 1 day and 2 weeks after the 13 diagnosed concussions.

Results: Cognitive abilities during gait were mainly affected after a concussion. A DT performance metric was defined based on features significantly associated with worsening DT performance after the concussion (P < .001, effect size d = 1.50). Finally, a model was proposed to estimate the risk of concussion based on a DT test outcome.

Conclusion: DT assessments can detect residual cognitive impairments even after other clinical symptoms have resolved. These tests offer medical staff objective insights, facilitating informed decision-making during the return-to-play process.

Objective: To determine whether there is a relationship between objective cognitive performance and self-reported cognitive status after mild traumatic brain injury (mTBI) and whether mental health symptoms influence this relationship.

Participants and design: Secondary analysis of the Federal Interagency Traumatic Brain Injury Research Informatics System database included an initial sample of 2657 participants. Cases with missing data, questionable validity, age over 65, or mild-complicated, moderate, or severe TBI were excluded resulting in a final sample of 614 individuals (n = 138 controls and n = 476 mTBI).

Main measures: Z-scores were derived using the Brief Test of Cognition by Telephone (BTACT) cognitive screener and the composite of the cognitive complaint items (CC) on the Rivermead Postconcussion Symptoms Questionnaire to represent objective and subjective cognitive status, respectively. The cognitive discrepancy was calculated by regressing BTACT on CC scores and retaining standardized residuals which produced a different score. A linear regression model was fitted using continuous cognitive discrepancy scores as the outcome and age, gender, time since injury, education, and mental health status (obtained via several self-report questionnaires) as predictors.

Results: Individuals with mTBI had higher affective symptoms and cognitive complaints but did not differ from controls based on objective cognitive abilities. Affective symptoms were significantly higher in individuals with mTBI who reported higher subjective complaints than expected based on cognitive scores. Older age, female gender, and increased emotional distress were associated with greater cognitive discrepancy in the whole sample.

Conclusions: Consistent with prior research, elevated psychological symptoms burden was associated with higher subjective cognitive complaints in relation to objective cognitive abilities. These results highlight the continued need for psychological intervention in post-mTBI recovery.