Journal of Head Trauma Rehabilitation最新文献

Objective: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) with traumatic brain injury (TBI) at 10 to 15 years post-injury and to identify unique predictors of unmet family needs.

Setting: Five Department of Veterans Affairs Polytrauma Rehabilitation Centers.

Participants: A total of 209 family caregivers of SMVs with TBI from the VA TBI Model Systems national database who completed a 10- or 15-year follow-up assessment.

Design: Observational study.

Main outcome measure: Family Needs Questionnaire-Revised (FNQ-R).

Results: Item-, domain-, and total score-level descriptive analyses of FNQ-R responses were conducted. On average, 56.3% of the FNQ-R family caregiver needs were reported as met. Health information and involvement in care needs were the most often met, and emotional support and instrumental support needs were the least often met. Adjusted multivariable regression models demonstrated that urban-dwelling SMVs (compared to suburban) and spouses/significant others (compared to parents) were associated with more unmet family needs. Distinct associations were identified between the 6 FNQ-R domains and SMV environmental factors (ie, urbanicity, rurality, and being active duty at follow-up), SMV comorbidities (ie, receiving mental health treatment in the year prior to the follow-up), and caregiver factors (ie, spouses/significant others).

Conclusion: Family caregivers of SMVs with TBI reported multiple unmet needs at 10 to 15 years post-injury, emphasizing the importance of ongoing caregiver support after TBI. Policy and programming to support military caregivers should consider the current findings to direct resources to address the identified unmet needs.

Objective: To present the results of a pilot study of On-TRACC (Tools for Recovery and Clinical Care), a novel intervention for individuals experiencing persistent cognitive difficulties after mild traumatic brain injury (mTBI). On-TRACC is a 5-session, 1:1 manualized treatment that integrates psychoeducation, cognitive rehabilitation strategies, and self-management skills to target symptoms and increase understanding of the interaction between cognitive difficulties, injury history, and comorbid medical and psychological conditions. The primary study goals were to evaluate the feasibility, acceptability, and preliminary effectiveness of On-TRACC.

Setting: Veterans Affairs medical center and an academic medical center.

Participants: Veterans and civilian adults (n = 28) >3 months post-mTBI with current self-reported cognitive difficulties.

Design: In this single-group, open-label pilot study, all participants received On-TRACC (5 sessions) via video-based telehealth.

Main measures: Primary measures were feasibility (eg, session attendance and homework completion rate, dropout rate, and treatment fidelity) and acceptability (treatment satisfaction/helpfulness ratings). Preliminary effectiveness was explored by measuring pre- to post-intervention change in cognitive symptom level and attribution, perceived self-efficacy, use of compensatory strategies, daily functioning, quality of life, and planned future engagement in health care.

Results: The On-TRACC completion rate for all enrolled participants was 79% (with 88% treatment completion rate for participants who started On-TRACC); homework was fully or partially completed for 98% of attended sessions. Treatment satisfaction ratings were high, with 95% satisfied with the information and skills learned. There were no adverse events. Positive pre- to posttreatment changes were seen in cognitive self-efficacy, symptom attribution, functional status, quality of life, and planned engagement in care for comorbid conditions.

Conclusion: On-TRACC was a feasible and acceptable intervention for individuals with chronic cognitive difficulties following mTBI. Additional research, including a randomized clinical trial, is needed to evaluate the efficacy of this intervention and its long-term impact on outcomes in this clinical population.

Objective: Traumatic brain injury (TBI) can result in new onset of comorbidities and limited studies suggest health care utilization following TBI may be high. Setting, Participants, Mean Measures, and Design: This study used 2018 and 2019 MarketScan Commercial Claims and Encounters data to examine differences in longitudinal health outcomes (health care utilization and new diagnoses) by various demographic factors (age, sex, U.S. region, intent/mechanism of injury, urbanicity, and insurance status) among individuals with and without a TBI in the year following an index health care encounter.

Results: Results show that within 1 year of the initial encounter, a higher percentage of patients with TBI versus without TBI had at least one outpatient visit (96.7% vs 86.1%), emergency department (ED) visit (28.5% vs 13.1%), or hospital admission (6.4% vs 2.6%). Both children (33.8% vs 23.4%) and adults (43.8% vs 31.4%) who sustained a TBI had a higher percentage of new diagnoses within 1 year compared to the non-TBI group. Additionally, individuals with a TBI had greater health care utilization across all types of health care settings (outpatient and inpatient), visits (ED visits and hospital admissions), and across all demographic factors (P < .001).

Conclusion: These results may inform future research around the development of systems of care to improve longer-term outcomes in individuals with TBI.

Objective: To estimate cost models of military traumatic brain injury (TBI) that can provide evidence for future cost-effectiveness analyses highlighted as a gap in the recent National Academies of Sciences, Engineering, and Medicine (NASEM) report on accelerating progress in TBI.

Setting: Military Treatment Facilities (MTFs) and community care facilities within the Military Health System (MHS).

Participants: 1,101 service members/veterans (SMV) diagnosed with a TBI and treated at a Veterans Administration (VA) Polytrauma Rehabilitation Center (PRC).

Design: This retrospective study analyzed healthcare costs in MTFs and community care facilities among SMVs diagnosed with TBI and treated at 1 of 5 VA PRCs. MTF and community care records were assessed.

Main measures: Annual MTF and community care inpatient and outpatient costs. TBI disability was measured by the Disability Rating Scale (DRS).

Results: Mean age was 31, with 9.8 years of service, and time in MHS post-TBI was 7.18 years. The mean annual inpatient cost was $22,126 in MTFs and $112,218 in community. The mean annual outpatient cost was $17,983 in MTFs and $9,141 in community. Each year of age was associated with $8,276 (95% CI 4,068-12,483), each day of acute care length of stay (LOS) before rehabilitation with $1,024 (95% CI 8-2039), and each additional point on the DRS with $10,858 (95% CI 4,273-17,442) higher costs.

Conclusion: Findings describe MHS annualized costs across acute and chronic stages in MTFs and the community and their association with SMVs' TBI disability measured by the DRS. These foundational cost data are critical for informing future hybrid design trials in TBI that examine the economic impact of TBI interventions being studied in future research.

Objective: To determine whether regional variations exist in functional outcomes of patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation facilities (IRFs) across the United States, while controlling for demographic and clinical variables.

Setting: Inpatient rehabilitation facilities (IRFs) across 4 U.S. regions: West, Midwest, South, and East.

Participants: Adult patients with open or closed TBI (Rehabilitation Impairment Codes 2.21 or 2.22) discharged from an IRF between 2016 and 2019.

Design: This is a retrospective analysis de-identified data from the Uniform Data System for Medical Rehabilitation. The study compared total functional independence measure (FIM) scores and discharge dispositions across the 4 regions.

Main measures: Primary outcomes were FIM scores at discharge, changes in FIM scores between admission and discharge, and community discharge rates, adjusted for demographic and clinical factors. Cohen's d effect sizes were calculated to assess the clinical significance of regional differences on FIM scores. Prevalence ratios were used for discharge disposition outcomes.

Results: Regional differences were identified in functional outcomes for patients with TBI. The West had the highest community discharge rate (80.9%) compared to the East (70.5%). Discharge FIM scores were significantly lower in the Midwest and East compared to the South (-1.98 and - 2.31, respectively, P < .01), while the West showed no significant difference from the South (-0.78, P = .11). Effect sizes for FIM total scores were small across regions, with Cohen's d for West versus South at 0.017, Midwest versus South at 0.047, and East versus South at 0.047. Prevalence ratios for community discharge showed minor differences: West versus South at 1.010, Midwest versus South at 0.937, and East versus South at 0.918; all without statistical significance.

Conclusions: Regional disparities in functional outcomes following inpatient rehabilitation for TBI were observed, particularly in community discharge rates and total FIM scores. However, based on the effect sizes and prevalence ratios, these differences may not be clinically meaningful and could not be fully explained by demographic and clinical factors. Further studies are needed to explore region-specific factors influencing rehabilitation efficacy to improve outcomes for patients with TBI nationwide.

Objective: To determine whether there are differences in healthcare utilization for chronic pain based on location (rural vs urban/suburban) or healthcare system (civilians vs Military Service Members and Veterans [SMVs]) after moderate-severe TBI.

Setting: Eighteen Traumatic Brain Injury Model Systems (TBIMS) Centers.

Participants: A total of 1,741 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview.

Primary measures: Sociodemographic, injury, function outcome, pain, and pain treatment characteristics.

Results: Participants were mostly male (72.9%), White (75.2%), civilian (76.9%), 46 years old on average, and had greater than high school education (59.9%). 32% of participants resided in rural areas and 67% in urban/suburban areas. No significant difference in healthcare utilization for chronic pain was observed between individuals living in rural versus urban/suburban locations after adjustment for relevant covariates. However, rural SMVs had odds ratios >3 for each major treatment category including medical services (OR = 3.56), exercise therapies (OR = 5.23), psychological services (OR = 4.43), complementary and alternative therapies (OR = 3.23), and pain rehabilitation program (OR = 4.16) compared to rural civilians. This same pattern of findings was seen SMVs in urban/suburban settings as well. Being married versus single, bachelor/graduate education versus high school or less, and employed versus unemployed all had odds ratios >1 for exercise therapies, psychological services, complementary and alternative therapies, and pain rehab program.

Conclusion: Contrary to initial hypotheses, there were no significant differences in healthcare utilization for chronic pain treatment comparing those in rural versus urban/suburban areas. However, differences were found between SMVs and civilians across both rural and urban/suburban locations suggesting that SMVs have more access to chronic pain treatment. The improved access to social and financial services afforded by VHA programs to SMVs may serve as a model for improving healthcare utilization in similar civilian populations.

Objective: Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type.

Setting: Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI.

Participants: A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study.

Main measures: The main measures are sex, age, time since injury, and Mayo-Portland Adaptability Inventory (4th edition; MPAI-4).

Design: Retrospective analyses of demographic variables and MPAI-4 Total, index, and subscale Rasch-derived T-scores on admission and discharge.

Results: Gains on MPAI-4 Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group ( F = 236.69, P < .001, partial η 2  = .101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score ( F = 22.65, P < .001, partial η 2  = .025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores ( F = 2.55, P = .018, partial η 2  = .01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes.

Conclusions: Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

Objective: Surveillance of traumatic brain injury (TBI), including concussion, in the United States has historically relied on healthcare administrative datasets, but these methods likely underestimate the true burden of TBI. The Centers for Disease Control and Prevention (CDC) has recently added TBI prevalence questions to several national surveys. The objective of this article is to summarize their recent efforts and report TBI prevalence estimates.

Setting: Surveys.

Participants: Adult and youth respondents to a series of national surveys.

Design: Recent nationally representative surveys with either 12-month or lifetime TBI prevalence questions were identified.

Main measures: For each data source, survey methodology, TBI definition, question wording, and prevalence estimates were examined.

Results: TBI prevalence varied depending on the question wording and data source. Overall 12-month prevalence of concussion/TBI among adults ranged from 2% to 12% while overall lifetime prevalence of concussion or TBI ranged from 19% to 29%. Overall 12-month prevalence of concussion/TBI among children and adolescents was 10% while 12-month prevalence of sports- and recreation-related concussion for youth ranged from 7% to 15%. Overall lifetime prevalence of TBI among youth ranged from 6% to 14%.

Conclusion: Survey data based on self-reported concussions and TBIs resulted in larger prevalence estimates than would be expected based on traditional surveillance methods. Analyses of the various surveys shows that how the questions are asked and what terminology is used can notably affect the estimates observed. Efforts can be made to optimize and standardize data collection approaches to ensure consistent measurement across settings and populations.

Objectives: Reexamine the item structure and reliability of the Mayo-Portland Adaptability Inventory (4th ed; MPAI-4) through Rasch analysis of admission and discharge scores for a large sample of adults with acquired brain injury (ABI) who participated in various types of posthospital brain injury rehabilitation (PHBIR) programs; (2) compare differential item functioning (DIF) for traumatic brain injury (TBI), stroke and other ABI; and (3) explore the viability of more specific subscales in addition to the established indices.

Setting: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community, Day Treatment, and Outpatient rehabilitation programs serving individuals with ABI.

Participants: A total of 2154 individuals with TBI, stroke, or other ABI.

Design: Retrospective analysis of de-identified admission and discharge data from the Foundation to Advance Brain Rehabilitation (FABR) consortium database.

Main measure: MPAI-4.

Results: After adjusting 4 misfitting items and eliminating 20 misfitting persons, the MPAI-4 demonstrated real person reliability/separation = 0.93/3.52 and real item reliability/separation = 1.00/24.02. Independent Rasch analyses by diagnostic category found similar reliabilities and separations. Residual item correlations and principal component analysis of residuals (PCAR) indicated areas of local dependence arranged hierarchically reflecting the full-scale item hierarchy and providing the basis for 3 new subscales of Physical Abilities, Cognitive Abilities, and Autonomy. DIF across diagnostic categories revealed differences in item elevations characteristic of typical patients in each category. Measure means and SDs were very similar across categories.

Conclusions: MPAI-4 items demonstrate very good person and item reliabilities for individuals with TBI, stroke, and other ABI at a level that supports individual evaluation. Variations in item calibrations across diagnostic categories reflect the differential characteristics of typical patients within categories. The entire measure provides an overall assessment of common sequalae of ABI, and standard indices used in combination with newly derived subscales provide more specific assessments of rehabilitation needs for treatment planning.