Journal of Head Trauma Rehabilitation最新文献

Objective: To examine associations of traumatic brain injury (TBI) with self-reported and clinical measures of hearing function.

Setting: Four US communities.

Participants: A total of 3176 Atherosclerosis Risk in Communities Study participants who attended the sixth study visit in 2016-2017, when hearing was assessed.

Design: Prospective cohort study. TBI occurring prior to the hearing assessment was defined using self-reported questions and "International Classification of Diseases-9th/10th Edition" (ICD-9/10) codes.

Main measures: Hearing function was assessed by self-reported questionnaires and clinically measured indices (audiometry [4-frequency pure tone average for each ear] and speech-in-noise testing). Linear, logistic, and multinomial logistic models adjusted for sociodemographics, vascular risk factors, and occupational noise exposure were used to examine associations.

Results: Participants were a mean age of 79 years, 59% were female, 21% were of self-reported Black race, and 33% had a history of TBI (median time from first TBI to hearing assessment: 39 years (25th-75th percentile = 19-63 years). Compared to participants without TBI, participants with prior TBI had higher age-adjusted prevalence of self-reported hearing loss (42.3% vs 35.3%), tinnitus (28.0% vs 23.8%), hearing aid use (23.4% vs 17.8%), pure tone average > 40 dB (30.6% vs 24.8%), and presence in the lowest quartile of speech-in-noise performance (27.6% vs 22.8%). With further adjustment, and particularly with adjustment for occupational noise exposure, associations with hearing measures were largely no longer statistically significant. In secondary analyses of associations of TBI frequency and severity with hearing function, results were similar to our main analyses, without evidence of dose-dependent associations.

Conclusions and relevance: In this community-based cohort, prior TBI was associated with impaired hearing on both self-reported and clinically measured assessments, but these associations were attenuated after adjustment for occupational noise exposure. These results underscore the importance of the consideration of loud noise exposures, which may confound associations of TBI with hearing, in future studies.

Objective: To examine the role of area-level variables (hospital density and social deprivation) in the experience of health care access and quality among individuals with traumatic brain injury.

Setting: Online questionnaire of community dwelling individuals Participants: 300 individuals with a history of traumatic brain injury with loss of consciousness.

Design: Cross-sectional observational survey.

Main measures: Barriers to Care Questionnaire, Social Deprivation Index, Hospital Density.

Results: In an unadjusted regression model, less social deprivation and higher hospital density were associated with better perceived health care access and quality. After adjusting for personal factors of race, ethnicity, age, injury severity, food insecurity, and housing insecurity, the effect of social deprivation was fully attenuated whereas the effect of hospital density on health care access and quality remained significant. A model containing only the personal factors demonstrated reduced health care access and quality among individuals identifying as Hispanic. However, this effect was non-significant with the inclusion of the area-level contextual factors in a fully adjusted model.

Conclusions: Higher area-level hospital density is associated with a reduction in perceived barriers to care among individuals with TBI. In addition, contextual, area-level data accounted for the reduced health care access and quality among Hispanic participants. Area-level data can provide explanatory value in the study of health disparities for people with TBI from underrepresented racial and ethnic groups.

Objective: Prior studies have reported associations between childhood physical abuse and intimate partner violence (IPV). However, there has been limited literature examining the relationship between pediatric brain injuries and IPV-related brain injuries later in life. We examined the association between childhood brain injuries and brain injuries sustained from IPV in adulthood.

Setting: Participants were recruited through Mass General Brigham's "Rally," social media, and information sheets distributed in locations likely to serve women in current or past abusive relationships (eg, domestic violence shelters, and IPV support programs).

Participants: Women who have experienced IPV with and without brain injury (n = 129), ages 19 to 69.

Design: Retrospective, cross-sectional study design.

Main measures: We administered the Ohio State University Traumatic Brain Injury Identification Method and the Brain Injury Severity Assessment to assess brain injury history, and the Childhood Trauma Questionnaire (CTQ). A logistic regression was used to examine the association between pediatric brain injuries and IPV-related brain injuries, adjusting for childhood trauma, years of education, and age.

Results: A majority of participants (64.3%) reported experiencing at least 1 IPV-related brain injury, and 30.2% experienced at least 1 childhood brain injury. Child abuse-related brain injuries occurred in 10.9% of the sample, whereas childhood brain injuries from other causes occurred in 19.4% of participants. Participants who sustained at least 1 childhood BI were significantly more likely to sustain a future IPV-related brain injury as an adult (OR = 4.652, P = .004). For each additional childhood BI sustained, participants were more likely to sustain an IPV-related BI (OR = 3.198, P = .005).

Conclusion: This study illustrates a high prevalence of childhood brain injuries among women who have experienced IPV and identifies an association between pediatric brain injuries and brain injuries due to partner violence in adulthood. Our findings speak to the urgency of increasing our understanding of childhood brain injuries and whether they or other related factors might confer an increased risk for brain injuries or possibly IPV later in life.

Objective: After a concussion, some patients develop persistent post-concussion symptoms, which interferes with functioning in daily life. A biopsychosocial explanation for the development and continuation of persistent post-concussion symptoms is the fear avoidance model (FAM). This study aimed to investigate the effectiveness and feasibility of an individual 14-week exposure therapy for patients with persistent symptoms after concussion.

Participants: Four participants from a medical psychology outpatient clinic participated in the study. Their age ranged between 51 and 68 years old (M = 62.8, SD = 7). The average length of time since the concussion was 10 months.

Design: A single-case experimental design (SCED) with nonconcurrent multiple baselines was used. Participants were randomly assigned to a baseline period (A phase) length between 21 and 42 days. The intervention phase (B phase) consisted of 14 treatment sessions in 14 weeks. The follow-up phase was 12 weeks.

Main measures: Participants answered questions on a visual analogue scale about their satisfaction with functioning in daily life, avoidance behavior, and symptoms experience on a daily basis during baseline and on a weekly basis during intervention and follow-up. Additional outcomes included symptom severity, catastrophizing, quality of life, participation, avoidance behavior, and feasibility interviews.

Results: Tau-U yielded significant effects (P < .05) on all measures when comparing intervention and follow-up with the baseline in 3 out of 4 participants. Satisfaction with daily life increased and avoidance behavior and post-concussion symptoms experienced decreased. Participants and therapists rated the intervention protocol with an average of 8.8 out of 10.

Conclusion: The findings suggest that exposure therapy seems effective and feasible in treating patients with persistent symptoms after concussion in a clinical setting. Larger randomized controlled trials or replication with SCED studies are advised to obtain additional evidence on the effectiveness of exposure for individuals with persistent symptoms after concussion.

Objective: Concussion accounts for more than 80% of people experiencing traumatic brain injury. Acute concussion is associated with characteristic cognitive and functional deficits that may persist for weeks to months. A subgroup of these patients (from 10% to 50%) have persistent symptoms referred to as chronic post-concussion syndrome (PCS). There are limited treatment options for these patients and the pathophysiology is poorly understood, though oxidative stress is thought to be a contributing factor. The purpose of this study was to evaluate whether an antioxidant, N-acetylcysteine (NAC), might be beneficial in patients with PCS.

Setting: Outpatient medicine center.

Participants: Fifty patients with chronic PCS for at least 3 months post injury.

Design: The patients with PCS were enrolled in this randomized unblinded clinical trial to receive the antioxidant NAC as a combination of daily oral and weekly intravenous infusions, or assigned to a waitlist control group where they would continue to receive standard of care.

Main measures: Resting-state functional connectivity (FC) magnetic resonance imaging (rsFC-MRI) was performed pre and post either NAC or the waitlist period along with cognitive, emotional, and sensory symptom assessments.

Results: The results demonstrated significant (P < .05) improvements in symptoms as determined by the Rivermead Post-Concussion Symptoms Questionnaire, Spielberger State-Trait Anxiety Inventory, and Profile of Mood Scale in the PCS group receiving NAC as compared to patients receiving ongoing standard care. Importantly, there were significant (P< .01) changes in FC in the NAC group, particularly in networks such as the default mode network, salience network, and executive control network. These changes in FC also correlated with improvements in symptoms.

Conclusions: In patients with chronic PCS, NAC treatment was associated with significant changes in resting state FC and improvement in a variety of symptoms, particularly cognitive and affective symptoms.

Objective: To examine the persistence of visual symptoms in mild traumatic brain injury (MTBI) during the first months after injury. It is important to recognize visual disturbances because they can delay return to normal activities, while they might be simultaneously treated by visual therapy. Here we describe the results from a 1-year follow-up study of visual disturbances after MTBI.

Participants and measures: The study group comprised 26 patients from the Brain Injury Clinic of the Helsinki University Hospital. Inclusion criterion was a high score (≥21p) on the Convergence Insufficiency Symptom Survey (CISS) at an appointment with a neurologist within 6 months after injury. The patients underwent baseline vision evaluation at 4 months on average and follow-up at 14 months after injury. The evaluation included tests for visual acuity, near point of convergence, convergence facility, near point of accommodation, accommodative facility, motility, heterophoria, binocular vision, dynamic visual acuity, and fusional vergence width at near and far distances. Further assessments included the Rivermead Post Concussion Questionnaire for posttraumatic symptoms, a visual analog scale for visual fatigue, and the Developmental Eye Movement Test for saccadic eye movements.

Results: Both CISS and Rivermead Post Concussion Questionnaire scores improved significantly from baseline to follow-up. The overall level of visual fatigue according to visual analog scale score was lower at follow-up, but the increase in visual fatigue (comparing fatigue before and after assessment session) was significant both at baseline and follow-up. In visual function assessments, spontaneous recovery from baseline to follow-up could be seen in vergence facility and pursuit eye movement but not in near point of convergence, near fusion, distance fusion, heterophoria, and dynamic visual acuity.

Conclusion: The results point out the importance of evaluation of visual disturbances after MTBI. Early detection of these disturbances may provide an opportunity to provide visual therapy.

Objective: To assess the relationship between follow-up visit timing and occurrence of the first subsequent health care seeking visit.

Setting: The province of British Columbia, Canada.

Participants: A total of 21 029 children and youth who were diagnosed with an initial concussion from January 1, 2016, to December 31, 2017. These data were obtained from Population Data BC.

Design: A retrospective, descriptive correlational study.

Main measures: Follow-up timing was measured categorically as timely (4 weeks), delayed (1-3 months), or no follow-up; the occurrence of a subsequent health care visit beyond 3 months postinjury was measured up to 12 months at 3-month intervals (ie, 4-6, 7-9, and 10-12 months). These variables were measured using diagnostic codes for concussion, post-concussion syndrome, and the 17 concussion symptoms.

Results: After controlling for sociodemographic characteristics, having a delayed follow-up, relative to timely follow-up, was associated with higher odds of a subsequent health care seeking visit at 4 to 6 months (odds ratio [OR] = 2.68; confidence interval [CI], 2.08-3.47), 7 to 9 months (OR = 1.71; CI, 1.21-2.40), and 10 to 12 months (OR = 1.67; CI, 1.13-2.48). In contrast to having a delayed follow-up, having no follow-up, relative to timely follow-up, was associated with not having a subsequent health care seeking visit at 4 to 6 months (OR = 0.57; CI, 0.48-0.67) and 7 to 9 months (OR = 0.79; CI, 0.66-0.96), respectively.

Conclusions: Follow-up visit timing after a concussion in children and youth is associated with subsequent health care seeking. Greater efforts are needed to investigate the importance of initial follow-up visit timing, as they may play an integral role in injury prevention and symptom management following injury.

Objective: Implementation research is essential to accelerating the public health benefits of innovations in health settings. However, the US National Academies of Sciences, Engineering, and Medicine 2022 report identified a lag in published implementation research applied to traumatic brain injury (TBI). Our objectives were to characterize implementation science studies published to date in TBI clinical care and rehabilitation and provide recommendations for future directions.

Methods: A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Articles published between 2011 and 2023 were identified (MEDLINE, PubMed, PsychInfo, and Web of Science), and included if the study focused on the TBI population, measured at least one Proctor (2011) implementation outcome and aligned with implementation research designs. Data were charted using an extraction template.

Results: Of the 38 articles, 76% were published between 2018 and 2023. About 37% of articles were in the pre-implementation phase, and 57.9% were in the implementation phase. Over half of articles used a theory, model, or framework to guide the research. Fifteen studies were descriptive, 10 were qualitative, 7 were mixed methods, and 4 were randomized controlled trials. Most studies investigated implementation outcomes regarding national guidelines following TBI or TBI symptom management. Adoption (42.1%) and fidelity (42.1%) were the most commonly studied implementation outcomes, followed by feasibility (18.4%), acceptability (13.2%), and penetration (10.5%). Only 55% of studies used or tested the effectiveness of one or more implementation strategies, with training and education used most commonly, followed by data warehousing techniques.

Conclusions: Future research should prioritize the selection and investigation of implementation strategy effectiveness and mechanisms across contexts of care and use implementation research reporting standards to improve study rigor. Additionally, collaborative efforts between researchers, community partners, individuals with TBI, and their care partners could improve the equitable translation of innovations across service contexts.

Objective: To describe a quality improvement project aimed at increasing collection of a "Core Set" of functional outcome measures in an inpatient rehabilitation facility (IRF), characterize implementation strategies used across 4 study phases, and evaluate program adoption and maintenance.

Setting: A 30-bed brain injury unit of a 132-bed IRF.

Participants: Participants included physical therapists (5 full-time, 2 part-time, and 30 hourly as needed) and 764 individuals with traumatic brain injury (TBI) who received care during the project period.

Design: In this descriptive observational study, we operationalize implementation strategies selected for 4 project phases: Exploration, Preparation, Implementation, and Sustainment. We define each implementation strategy using the Expert Recommendations for Implementing Change and report on program adoption and maintenance.

Main measures: Adoption (proportion of TBI-related admissions with completed outcome measures) and maintenance (adoption over 4 years).

Results: Preparation phase strategies focused on local adaptations, education, environmental preparation, and collaboration with informatics. Implementation phase strategies included reminders, feedback, champions, and iterative adjustments. Sustainment strategies focused on integration into standard practice. Adoption increased postinitiation for all measures except one. Despite improvements, a notable portion of measures remained incomplete. Increases in outcome measure collection were maintained for 2 to 4 years, but a significant decline in paired admission and discharge scores suggests a reduced ability to monitor change over time.

Conclusions: This study provides an example of a clinically driven quality improvement project and selected implementation strategies used to increase the collection of standard outcome measures in IRF. By leveraging the Expert Recommendations for Implementing Change framework, we aim to enhance comparability with similar efforts elsewhere. The results demonstrate the program's successes and challenges, highlighting the need for interdisciplinary clinical and research collaboration to support the translation of knowledge between research and clinical practice and inform meaningful improvements in care across TBI rehabilitation.