Journal of Head Trauma Rehabilitation最新文献

Background: The Workplace Safety and Insurance Board (WSIB) in Ontario, Canada, launched a new community-based mild traumatic brain injury (mTBI) program of care (POC) in November 2020. The new program included graded exercise therapy and vestibular rehabilitation (where required). The objective of this study was to assess the impact of the new mTBI POC on recovery and return to work among patients who suffered a work-related mTBI.

Methods: We identified WSIB claims that accessed the previous and new mTBI POC over a 4-year timeframe (October 1, 2017, to September 30, 2019, and July 1, 2021, to June 30, 2023). A quasi-experimental pre-post study, propensity score matching design with a difference-in-difference modelling component was applied to approximate estimation of causal effects on loss of earnings (LOE) benefit duration at 3-, 6-, and 12-months and HC costs for patients treated in the previous and new programs.

Results: Over the 4-year timeframe, 5625 patients accessed the previous and new mTBI POC. The new program achieved improved 3-, 6-, and 12-month disability durations (incremental percentage difference of -11.7%, -9.3%, and -9.0%, respectively), and shorter durations of disability, reflected by decreased LOE benefit costs (incremental percentage difference of -32.6%) and decreased HC costs (incremental percentage difference of -5.6%). The overall combined savings in LOE and HC costs was 21%.

Conclusions: This analysis indicates that the implementation of this new evidence based mTBI POC resulted in improved outcomes (decreased disability duration and lower health care utilization) on a per patient basis for people with work-related mTBI.

Objective: Examine effects of 8-week Behavioral Activation (BA)-based treatment on emotional distress in moderate-severe traumatic brain injury (msTBI).

Setting: Single TBI rehabilitation center.

Participants: Sixty community-dwelling persons with msTBI sustained ≥6 months prior, with at least mild depression and/or anxiety but no suicidal ideation/ psychiatric instability.

Design: Randomized controlled trial comparing 2 treatments: the BAT condition delivered in 8 sessions of BA (6 face-to-face, 2 phone) with ecological momentary assessment (EMA) and text reminders for increased activity; the INT condition, shown in a previous trial to be highly credible and mildly efficacious, used 1 face-to-face session plus 8 weeks of text reminders framed as implementation intentions for increased activity.

Main measures: Global Severity Index of Brief Symptom Inventory-18 (BSI-18 GSI; primary outcome); secondary outcome measures of hypothesized BA mechanisms (environmental reward, activation); participation; and quality of life assessed at baseline, post-treatment, 2-month follow-up; Patient Global Impression of Change (PGIC) measured post-treatment.

Results: Primary analysis revealed that BAT participants with higher baseline emotional distress had significantly greater improvement in distress (primary outcome) compared to INT participants at post-treatment; this response was attenuated at follow-up. Across distress levels, both measures of BA mechanism showed superior response to BAT at post-treatment and at follow-up. Other secondary outcomes did not differ significantly by treatment, although there was a trend for BAT participants to show more improved health-related quality of life. BAT participants reported significantly greater degree of meaningful change post-treatment (PGIC).

Conclusions: Findings support a growing body of research suggesting that structured, theoretically based approaches to increasing activity linked to personal values can have substantial beneficial impact for many persons with chronic msTBI and emotional distress. Promising future directions include adapting the BAT treatment to remote delivery to improve its potential reach.

Objective: Define and characterize extreme phenotypes of pain catastrophizing for persons with chronic pain following mild to severe traumatic brain injury (TBI) requiring inpatient rehabilitation.

Setting: 18 TBI Model System (TBIMS) centers.

Participants: 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain.

Design: Cross-sectional, secondary analyses.

Primary measures: Catastrophizing, sociodemographic, injury, functional outcome, pain, and treatment characteristics.

Results: Participants were male predominantly (73%), White (76%), middle-aged (mean 46.5 years), injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25 th percentiles to create low catastrophizing (N = 434) and high catastrophizing (N = 458) groups. Bivariate comparisons found significant differences ( P < .001) on all measures of concurrent function and pain interference with those in the low catastrophizing phenotype experiencing better function and lower pain interference than those in the high catastrophizing phenotype. Combination Lasso and logistic regression identified multivariable predictors of phenotypes. Increased odds of high versus low catastrophizing extreme phenotypes were associated being younger (odds ratio [OR] = 1.24 for a 10-unit decrease), less than a college level of education (OR = 1.70-2.53), no military history (OR = 3.25), lower FIM motor (OR = 1.20 for a 5-unit decrease) and cognitive (OR = 1.53 for a 5-unit decrease) scores, increased pain intensity (OR = 1.22 for a 1 unit increase) and pain interference (OR = 1.93 for a 1-unit increase), neuropathic type pain (OR = 1.82-1.86), and migraine type pain versus no head pain (OR = 1.65).

Conclusion: High pain catastrophizing phenotypes were associated with a greater degree of pain and functional disability and higher likelihood of neuropathic pain and migraine headache. Given pain catastrophizing's contribution to pain-related disability and treatment outcomes, additional research is necessary to investigate its role in adjustment to chronic pain among individuals with TBI. Adapting evidence-based interventions for this population that specifically targets pain catastrophizing is warranted.

Objective: Determine the prevalence of undiagnosed concussions across the lifespan and their association with demographic and injury-related factors, prolonged recovery, and risk for subsequent injury. Test the hypothesis that prior diagnosed and undiagnosed concussions are associated with worse current-day concussion-related symptoms.

Setting: Academic medical center.

Participants: Healthy collegiate-aged athletes with varying levels of prior concussion (N = 212, age 21.00 ±1.69 years, 63% male; N = 125, age 21.05 ±1.67 years, 66% male) with at least 1 prior concussion.

Design: In this cross-sectional single-visit study, semi-structured interviews were used to retrospectively collect concussion history across the lifespan, including whether concussion was diagnosed at time of injury. Generalized linear models determined association of injury-related and demographic factors with diagnosis status at time of injury. Multiple linear regression determined associations of number of diagnosed and undiagnosed concussions with current concussion-related symptom severity.

Main measures: Diagnosis status, days until and number of subsequent concussions, number of days with symptoms for retrospectively identified concussions; Sport Concussion Assessment Tool symptom severity.

Results: Fifty-three percent of the 308 concussions retrospectively identified were not diagnosed as concussion at time of injury. Older age ( P = .045, OR = 1.08), greater number of endorsed symptoms ( P <. 001, OR = 1.22), presence of post-traumatic amnesia ( P = .011, OR = 2.47), and presence of retrograde amnesia ( P = .012, OR = 3.19) at the time of injury increased odds of that injury being diagnosed as concussion. Injuries diagnosed as concussion at time of injury were associated with greater number of days with symptoms (B = 11.26(2.01), P < .001). A greater number of diagnosed concussions (B(SE) = 0.19 (0.06), P = .003), and to a lesser extent undiagnosed concussions (B(SE) = 0.11(.06), P = .08), were associated with current symptom severity.

Conclusions: Most concussions experienced by collegiate-aged athletes throughout their life go undiagnosed. Findings do not support the hypothesis that undiagnosed concussions are associated with worse chronic symptom reporting relative to diagnosed concussions but illustrate the need to consider both when characterizing potential long-term effects.

Traumatic brain injury (TBI) is a known risk factor for delirium, a condition associated with prolonged hospitalization and cognitive deterioration. Although the relationship between TBI and delirium is established, the influence of traumatic lung injuries on delirium development is less understood. Respiratory disorders can significantly influence the central nervous system, with sequelae such as hypoxia and hypercapnia causing neurologic dysfunction. Therefore, we hypothesized that TBI patients suffering lung-associated conditions, stemming either from traumatic lung injury (TLI) or subsequent pulmonary surgery will be associated with an increased risk of developing delirium.

Methods: The 2021 Trauma Quality Improvement Program database was queried for patients with TBI, excluding those with pre-existing dementia. TBI patients developing delirium were compared to those without delirium. A multivariable logistic regression analysis was performed to determine pulmonary and neurogenic-associated risk factors for delirium.

Results: Among 155,252 TBI patients, 3244 (2.1%) developed delirium. Delirium-afflicted patients showed elevated rates of TLI (25.0% vs 13.3%, p < .001), severe head trauma (51.4% vs 37.8%, p < .001), sepsis (3.1% vs 0.5%, p < .001) and more commonly underwent pulmonary operations (21.8% vs 6.6%, p < .001). The strongest associated risk factors for delirium included unplanned intubation (OR 2.79, CI 2.47-3.16, p < .001), pulmonary surgery (OR 1.47, CI 1.32-1.63, p < .001), COPD (OR 1.52, CI 1.34-1.72, p < .001), TLI (OR 1.25, CI 1.14-1.38, p < .001), and severe head injury (OR 1.12, CI 1.04-1.22, p = .003).

Conclusion: Delirium affects approximately 2% of the national TBI population. Our study reveals an influence of lung-related conditions for delirium onset. These results emphasize the intimate relationship of the brain and pulmonary system. Future prospective studies are needed to validate these findings as they may impact TBI management and outcomes.

Objective: To examine the factor structure and validity of the 40-item common misconceptions in traumatic brain injury (CM-TBI) scale, and to develop and evaluate additional concussion-focussed items to broaden the instrument's scope.

Method: A purposive sample of 988 participants from across all habitable continents (M age 43, range 16-90 years, 84% female) completed the CM-TBI and 5 additional concussion items at commencement of an online course on TBI.

Results: Item analysis resulted in the removal of 19 items due to ambiguous wording and poor conceptual integrity, and/or low discrimination and low inter-item correlations. An exploratory factor analysis on the remaining 26 items revealed a 3-factor model had best fit, with an additional 8 items removed due to low or cross-loadings, low communalities, and/or low conceptual relevance, resulting in an 18-item revised scale.

Conclusion: There is no psychometric support for the current structure of the CM-TBI. This is likely due to changes in understanding of TBI since the scale's inception, and issues of conceptual ambiguity. It is also proposed that a distinction must be made between knowledge and misconceptions, as these are 2 related but different constructs that are not clearly delineated in the current CM-TBI. Using the revised scale here offers researchers a more modern, focussed, and valid measure, but a new scale to measure knowledge and misconceptions in TBI is urgently needed.

Significant progress has been achieved in understanding recovery from severe brain injury and resulting disorders of consciousness (DoC) since the inaugural issue of the Journal of Head Trauma Rehabilitation in 1986. Research across all biomedical sciences has sharpened diagnostic distinctions and increased prognostic accuracy and has led to the development of improved assessment strategies, pharmacologic and nonpharmacologic treatments. This article highlights achievements in these domains since the last update was provided 20 years ago. Unparalleled translation into clinical practice has been achieved in DoC compared to many areas in rehabilitation. International collaboration among scientists, clinicians, and professional organizations has resulted in critical partnerships that have helped to move evidence into practice. Specifically, evidence-based guidelines and position statements, funded and/or endorsed by interdisciplinary organizations, have helped to guide the field toward implementation. Further, public initiatives such as the Curing Coma Campaign initiated by the Neurocritical Care Society and the Model Systems Knowledge Translation Center funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) have created international engagement using traditional and online media with expansive reach. The cumulative evidence and clinical guidance endorsed by multiple professional organizations have informed the development of quality-of-care standards for DoC rehabilitation that will be published in the CARF Medical Rehabilitation Standards Manual, which goes into effect July 1, 2026. Quality of care initiatives to improve implementation of DoC evidence-based care are creatively pursued by researchers via traditional funding agencies such as NIDILRR, the Department of Defense, and professional organizations and are highlighted as exemplars. Lastly, milestones for the next 20 years highlighting acceleration in research, discovery, and innovation in DoC are described.

Objective: Qualitative evidence suggests that disability stigma is an important concept in the lived experiences of individuals with traumatic brain injury (TBI). However, there have been no studies in this population specifically evaluating internalized disability stigma. We sought to characterize variability in levels of internalized stigma and examine the applicability of the "why try" effect (reduced self-efficacy and life goal attainment as consequences of internalized stigma) to people living with chronic TBI.

Setting: Outpatient research laboratory.

Participants: Eighty-four adults with chronic TBI (1.4-22.6 years post-injury).

Design: Cross-sectional observational study.

Main measures: Items were adapted from the Internalized Stigma of Mental Illness questionnaire to capture disability-related internalized stigma and perceived discrimination. Primary outcome measures included societal participation and self-efficacy for TBI symptom management, which were assessed using validated instruments (Participation Assessment with Recombined Tools-Objective and TBI Self-Efficacy Scale, respectively).

Results: Raw and residualized (adjusted for perceived discrimination) internalized stigma scores were normally distributed. Individuals who reported internalized stigma at levels greater than predicted by their perceived discrimination tended to have more recent injuries ( d = .60) and poorer processing speed ( d = .50) compared to those reporting relatively lower internalized stigma. Higher internalized stigma was associated with lower self-efficacy, which, in turn, was associated with lower societal participation (indirect effect = - .26, 95% CI = [-.50, - .09]), independent of mental health symptoms.

Conclusions: Findings provide preliminary support for clinically meaningful variability in internalized stigma among people with TBI, and for the applicability of the "why try" model to this population. Further theory-informed research could stimulate the development of behavioral health interventions for reducing stigma internalization and its harmful effects on post-injury psychosocial functioning.

In this retrospective essay celebrating the 40th anniversary of the Journal of Head Trauma and Rehabilitation, Dr. Joseph J. Fins traces the evolution of the neuroethics of disorders of consciousness through autobiographical reflections over the past four decades. His memoir highlights his origins as a medical student on the Cornell Neurology Service headed by Dr. Fred Plum, the co-originator of the Persistent Vegetative State with Dr. Bryan Jennett and culminates with his collaboration with Dr. Nicholas Schiff and the clinical and ethical importance of Cognitive Motor Dissociation in clinical care. During this period Fins describes the therapeutic nihilism that followed in the wake of landmark end-of-life cases like Quinlan, Cruzan and Schiavo and how scientific advance and an emerging nosology has begun to envision therapeutic possibility informed by an expanded nosology and neuroimaging. Fins asserts that the disability rights of people with disorders of consciousness need to be accommodated in tandem with access to technological advance in order to more fully integrate these individuals into the nexus of their families and communities. Fins argues that the developments of the past 40 years are a harbinger of further progress but cautions that this will not occur without sustained government support from the National Institutes of Health.

Objective: Individuals with traumatic brain injury (TBI) often experience residual mobility deficits that can be improved with treadmill and virtual reality interventions. However, previous studies have not measured the underlying neurophysiology during these interventions nor assessed if acquiring such data is feasible in a TBI population. Thus, the primary purpose of this study was to assess the feasibility of using portable functional near-infrared spectroscopy (fNIRS) to measure neurophysiology during a treadmill task and a treadmill with virtual reality task.

Setting: Data were collected in an outpatient setting at Craig Hospital.

Participants: Eight individuals with chronic moderate to severe TBI were recruited. The primary eligibility criteria include age of 18 years or older, diagnosis of moderate to severe TBI that initially required inpatient rehabilitation at least 1 year prior and could walk at least 10 feet without support from more than 1 person.

Design: Cross-sectional feasibility study. Participants were assessed with fNIRS while completing a 12-minute treadmill task and a 12-minute treadmill with virtual reality task. Feasibility benchmarks were established a priori and included safety, acceptability, data acquisition and quality metrics.

Main measures: Pre-determined feasibility objectives served as the primary outcome of this study. Global brain activity as measured by FNIRS was acquired during treadmill training alone and treadmill training with virtual reality in early, middle, and late epochs.

Results: The fNIRS protocol used in this study was safe for all participants and acceptable to 87.5% of participants. FNIRS data acquisition and quality benchmarks were achieved for 87.5% participants. Exploratory fNIRS analyses revealed significantly greater global brain activity during the treadmill with virtual reality task compared to the treadmill task alone in late epochs. No adverse events occurred.

Conclusion: All feasibility benchmarks were achieved suggesting that this fNIRS protocol can be used in future, larger-scale studies.