Feasibility of a Brief Neuropsychologic Test Battery During Acute Inpatient Rehabilitation After Traumatic Brain Injury

Therapeutic assessment and the art of feedback: A model for integrating evidence-based assessment and therapy techniques in neurological rehabilitation

BACKGROUND

Therapeutic assessment involves the integration of evidence-based approaches and humanistic principles, and there is empirical support for the use of this approach in the context of neuropsychological assessment broadly.

OBJECTIVE

We propose that therapeutic assessment (TA) and collaborative therapeutic neuropsychological assessment (CTNA) principles are appropriate and effective for application within a neurological rehabilitation population specifically.

METHODS

We review TA and CTNA principles and propose a model for their application to a neurological rehabilitation population, with an emphasis on describing the strengths of the collaborative approach, guidelines and principles for maximizing the efficacy of feedback, and transitioning the patient into psychotherapy services to further address their personal goals. A case example of a neurologically injured individual engaged in CTNA and subsequent intervention is shared to highlight the principles discussed.

RESULTS AND CONCLUSION

The proposed model and case study demonstrate the clinical utility of TA and CTNA principles with a neurological rehabilitation population.

Neuropsychological and behavioral disorders, functional outcomes and quality of life in traumatic brain injury victims

INTRODUCTION

the assessment of neuropsychological and behavioral disorders outcomes, functional outcomes and quality of life in traumatic brain injury victims. It was also to evaluate initial means of care provided to these patients. Finally, to study correlations between neuropsychological and behavioral disorders with demographic characteristics, injury severity, functional status and quality of life.

METHODS

it was a cross-sectional study including 50 patients with traumatic brain injury conducted in the physical medicine and rehabilitation department of Sfax. Memory disorders were tested by the mini mental state and the Glaveston orientation and amnesia tests. Executive functions were evaluated by the dysexecutive function scale. The psychological profile was evaluated using the hospital anxiety and depression scale and behavioral disorders were tested by the agitated behavior scale. Glasgow outcome scale has allowed the assessment of traumatic brain injury severity in terms of disability. Otherwise, functional capacity was measured by functional independence measure scale. Finally, health-related quality of life was measured using a generic measure (short-form-36) and the QOLIBRI scales.

RESULTS

abnormal executive functions were noted in 41 patients (82%) with a dysexcutive function average score of 33.20 ± 22.74. About psychological profile, depressive symptoms were found in 32 patients (64%). Moreover anxiety was noted in 20 patients (40%). Behavioral disorders such as aggressiveness and agitation were noted respectively in 32 (64%) and 8 patients (16%). The global social functional evolution was considered as unfavorable in 42% of the patients and favorable in 58%. Regarding to functional independence measure scale, 92% of the victims showed impairment. Memory impairment and abnormal executive functions were statistically correlated with traumatic brain injury severity. Elementary brain injury lesions shown on computed tomography were correlated with memory disorders especially for temporal, cortical brain contusion and diffuse axonal injury. Our study showed that patients with severe memory impairment, abnormal executive functions and depressive mood had significant functional.

CONCLUSION

the executive function disorders, depressed mood and the memory disorders seemed to be the most frequent among neuropsychological disorders in traumatic brain injury. We noted that it is so important to evaluate neuropsychological disorders in traumatic brain injury because they were underestimated. We have already started this experience despite the lack of means in our department. The evaluation of the executive function in addition to the classic neuropsychological assessment is essential to propose efficient means of rehabilitation.

More than amnesia: prospective cohort study of an integrated novel assessment of the cognitive and behavioural features of PTA

Background and Objective:

Post-traumatic amnesia (PTA) is an early significant stage of recovery from traumatic brain injury (TBI). Current prospective PTA scales do not assess the full range of PTA symptomatology. This study conducted a novel integrated assessment of cognition and behaviour during PTA.

Method:

Twenty-four moderate-to-severe TBI participants in PTA and 23 TBI controls emerged from PTA were matched for age, gender, and years of education. All completed PTA measures (Galveston Orientation and Amnesia Test: GOAT, Westmead Post-traumatic Amnesia Scale: WPTAS), a cognitive battery; and behaviour ratings scored by 2 independent raters (informant and staff).

Results:

Significantly poorer performance was found during PTA for attention, processing speed, delayed verbal free recall and recognition, and visual learning. A large effect size was found for category fluency only. Behaviour ratings were significantly higher during PTA. Five behaviours were rated as high frequency (>50%) by both raters: Inattention, Impulsivity, Sleep Disturbance, Daytime Arousal, and Self-Monitoring. Prospective PTA measures produced significantly different duration estimates from 2 days (GOAT vs. WPTAS 1st day) to 9 days (WPTAS 1st day vs. 3-day). The WPTAS correlated most highly with processing speed and language tasks; whilst the GOAT correlated most highly with language and executive control of verbal memory.

Conclusion:

New prospective measures are needed that integrate core cognitive and behavioural features are brief, easy to administer, and capable of measuring emergence. The term PTA is a misnomer that requires revision to better accommodate the clinical syndrome.

Concordance between current American Academy of Sleep Medicine and Centers for Medicare and Medicare scoring criteria for obstructive sleep apnea in hospitalized persons with traumatic brain injury: a VA TBI Model System study

STUDY OBJECTIVES

The objective of this study was to compare obstructive sleep apnea (OSA), demographic, and traumatic brain injury (TBI) characteristics across the American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicare (CMS) scoring rules in moderate to severe TBI undergoing inpatient neurorehabilitation.

METHODS

This is a secondary analysis from a prospective clinical trial of sleep apnea at 6 TBI Model System study sites (n = 248). Scoring was completed by a centralized center using both the AASM and CMS criteria for OSA. Hospitalization and injury characteristics were abstracted from the medical record, and demographics were obtained by interview by trained research assistants using TBI Model System standard procedures.

RESULTS

OSA was prevalent using the AASM (66%) and CMS (41.5%) criteria with moderate to strong agreement (weighted κ = 0.64; 95% confidence interval = 0.58-0.70). Significant differences were observed for participants meeting AASM and CMS criteria (concordant group) compared with those meeting criteria for AASM but not CMS (discordant group). At an apnea-hypopnea index ≥ 5 events/h, the discordant group (n = 61) had lower Emergency Department Glasgow Coma Scale Scores consistent with greater injury severity (median, 5 vs 13; P = .0050), younger age (median, 38 vs 58; P < .0001), and lower body mass index (median, 22.1 vs 24.8; P = .0007) compared with the concordant group (n = 103). At an apnea-hypopnea index ≥ 15 events/h, female sex but no other differences were noted, possibly because of the smaller sample size.

CONCLUSIONS

The underestimation of sleep apnea using CMS criteria is consistent with prior literature; however, this is the first study to report the impact of the criteria in persons with moderate to severe TBI during a critical stage of neural recovery. Management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Given the chronic morbidity after moderate to severe TBI, the impact of CMS policy for OSA diagnosis for persons with chronic disability and young age are considerable.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome; Identifier: NCT03033901.

Comparison of Diagnostic Sleep Studies in Hospitalized Neurorehabilitation Patients With Moderate to Severe Traumatic Brain Injury

BACKGROUND

OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI.

RESEARCH QUESTION

This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI.

STUDY DESIGN AND METHODS

This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days).

RESULTS

Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764).

INTERPRETATION

Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

The Role of Cognitive Reserve in Recovery From Traumatic Brain Injury

OBJECTIVE

To examine whether cognitive reserve (CR) attenuates the initial impact of traumatic brain injury (TBI) on cognitive performance (neural reserve) and results in faster cognitive recovery rates in the first year postinjury (neural compensation), and whether the advantage of CR differs on the basis of the severity of TBI.

SETTING

Inpatient/outpatient clinics at an academic medical center.

PARTICIPANTS

Adults with mild TBI (mTBI; n = 28), complicated mild TBI (cmTBI; n = 24), and moderate to severe TBI (msevTBI; n = 57), and demographically matched controls (n = 66).

DESIGN

Retrospective, longitudinal cohort assessed at 1, 6, and 12 months postinjury.

MAIN MEASURES

Outcomes were 3 cognitive domains: processing speed/executive function, verbal fluency, and memory. Premorbid IQ, estimated with the Wechsler Test of Adult Reading, served as CR proxy.

RESULTS

Higher premorbid IQ was associated with better performance on cognitive domains at 1 month postinjury, and the effect of IQ was similarly beneficial for all groups. Cognitive recovery rate was moderated only by TBI severity; those with more severe TBI had faster recovery in the first year.

CONCLUSION

Results support only the neural reserve theory of CR within a TBI population and indicate that CR is neuroprotective, regardless of the degree of TBI. Higher premorbid CR does not allow for more rapid adaptation and recovery from injury.

Neuropsychological Characteristics of the Confusional State Following Traumatic Brain Injury

OBJECTIVES

Individuals with moderate-severe traumatic brain injury (TBI) experience a transitory state of impaired consciousness and confusion often called posttraumatic confusional state (PTCS). This study examined the neuropsychological profile of PTCS.

METHODS

Neuropsychometric profiles of 349 individuals in the TBI Model Systems National Database were examined 4 weeks post-TBI (±2 weeks). The PTCS group was subdivided into Low (n=46) and High Performing PTCS (n=45) via median split on an orientation/amnesia measure, and compared to participants who had emerged from PTCS (n=258). Neuropsychological patterns were examined using multivariate analyses of variance and mixed model analyses of covariance.

RESULTS

All groups were globally impaired, but severity differed across groups (F(40,506)=3.44; p&lt;.001; ŋp 2 =.206). Rate of forgetting (memory consolidation) was impaired in all groups, but failed to differentiate them (F(4,684)=0.46; p=.762). In contrast, executive memory control was significantly more impaired in PTCS groups than the emerged group: Intrusion errors: F(2,343)=8.78; p&lt;.001; ŋ p 2=.049; False positive recognition errors: F(2,343)=3.70; p&lt;.05; ŋp 2=.021. However, non-memory executive control and other executive memory processes did not differentiate those in versus emerged from PTCS.

CONCLUSIONS

Executive memory control deficits in the context of globally impaired cognition characterize PTCS. This pattern differentiates individuals in and emerged from PTCS during the acute recovery period following TBI. (JINS, 2019, 25, 302-313).

Predictors of Satisfaction With Life in Veterans After Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To identify predictors of satisfaction with life in Veterans 1 year after traumatic brain injury (TBI).

SETTING

The VA TBI Model Systems (TBIMS) project includes 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

Veterans enrolled in the VA TBIMS study who completed the Satisfaction With Life Scale at year 1 follow-up. The sample is largely male (96%) and Caucasian (72%), with a median age of 27 years upon enrollment.

DESIGN

Prospective observational cohort study measuring including demographics (eg, education), preinjury variables (eg, mental health history and employment), and military variables (eg, injury during deployment and injury during active duty status).

MAIN OUTCOME MEASURE

Satisfaction With Life Scale.

RESULTS

Multivariate regression analyses revealed that age, marital status, preinjury employment status, preinjury mental health history, and active duty status at the time of injury were significant predictors of life satisfaction at year 1 follow-up.

CONCLUSIONS

Results of this study suggest that satisfaction with life in Veterans with TBI is mediated by several factors that might inform rehabilitation interventions and discharge recommendations. Preinjury variables and active duty status (a unique aspect of the Veteran population) influence life satisfaction at 1 year postinjury. Limitations and future clinical implications will be discussed.

Neurocognitive Models of Medical Decision-Making Capacity in Traumatic Brain Injury Across Injury Severity

OBJECTIVE

To identify neurocognitive predictors of medical decision-making capacity (MDC) in participants with mild and moderate/severe traumatic brain injury (TBI).

SETTING

Academic medical center.

PARTICIPANTS

Sixty adult controls and 104 adults with TBI (49 mild, 55 moderate/severe) evaluated within 6 weeks of injury.

DESIGN

Prospective cross-sectional study.

MAIN MEASURES

Participants completed the Capacity to Consent to Treatment Instrument to assess MDC and a neuropsychological test battery. We used factor analysis to reduce the battery test measures into 4 cognitive composite scores (verbal memory, verbal fluency, academic skills, and processing speed/executive function). We identified cognitive predictors of the 3 most clinically relevant Capacity to Consent to Treatment Instrument consent standards (appreciation, reasoning, and understanding).

RESULTS

In controls, academic skills (word reading, arithmetic) and verbal memory predicted understanding; verbal fluency predicted reasoning; and no predictors emerged for appreciation. In the mild TBI group, verbal memory predicted understanding and reasoning, whereas academic skills predicted appreciation. In the moderate/severe TBI group, verbal memory and academic skills predicted understanding; academic skills predicted reasoning; and academic skills and verbal fluency predicted appreciation.

CONCLUSIONS

Verbal memory was a predictor of MDC in controls and persons with mild and moderate/severe TBI. In clinical practice, impaired verbal memory could serve as a "red flag" for diminished consent capacity in persons with recent TBI.

Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury

OBJECTIVES

To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties.

SETTING

VA Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data.

DESIGN

Prospective, longitudinal cohort.

MAIN MEASURES

Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning.

RESULTS

In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability.

CONCLUSION

Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

The Wechsler Test of Adult Reading as a Measure of Premorbid Intelligence Following Traumatic Brain Injury

OBJECTIVE

The current study sought to determine whether the Wechsler Test of Adult Reading (WTAR) provides a stable estimate of premorbid intellectual ability in acutely injured patients recovering from traumatic brain injury (TBI).

METHOD

A total of 135 participants (43 mild TBI [mTBI], 40 moderate/severe TBI [msevTBI], 52 healthy controls) were administered the WTAR at 1 and 12 months post-injury.

RESULTS

Despite similar demographic profiles, participants with msevTBI performed significantly worse than controls on the WTAR at both time points. Moreover, the msevTBI group had a significant improvement in WTAR performance over the 1-year period. In contrast, those participants with mTBI did not significantly differ from healthy controls and both the mTBI and control groups demonstrated stability on the WTAR over time.

CONCLUSIONS

Results indicate that word-reading tests may underestimate premorbid intelligence during the immediate recovery period for patients with msevTBI. Clinicians should consider alternative estimation measures in this TBI subpopulation.

Neuropsychological assessment without upper limb involvement: a systematic review of oral versions of the Trail Making Test and Symbol-Digit Modalities Test

The Trail Making Test (TMT) and written version of the Symbol Digit Modalities Test (SDMT) assess attention, processing speed, and executive functions but their utility is limited in populations with upper limb dysfunction. Oral versions of the TMT and SDMT exist, but a systematic review of their psychometric properties and clinical utility has not been conducted, which was the goal of this study. Searches were conducted in PubMed and PsycINFO, test manuals, and the reference lists of included articles. Four measures were identified: the SDMT-oral, oral TMT-A, oral TMT-B, and the Mental Alternation Test (MAT). Two investigators independently reviewed abstracts to identify peer-reviewed articles that reported on these measures in adult populations. From each article, one investigator extracted information on reliability, validity, responsiveness, minimum detectable change, normative data, and demographic influences. A second investigator verified the accuracy of the data in a random selection of 10% of papers. The quality of the evidence for each psychometric property was rated on a 4-point scale (unknown, poor, adequate, excellent). Results showed excellent evidence for the SDMT-oral, adequate evidence for the oral TMT-B and MAT, and adequate to poor evidence for the oral TMT-A. These findings inform the clinical assessment of attention, processing speed, and executive functions in individuals with upper limb disability.

Pumping the Brakes: Neurotrophic Factors for the Prevention of Cognitive Impairment and Dementia after Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of disability and death worldwide, affecting as many as 54,000,000-60,000,000 people annually. TBI is associated with significant impairments in brain function, impacting cognitive, emotional, behavioral, and physical functioning. Although much previous research has focused on the impairment immediately following injury, TBI may have much longer-lasting consequences, including neuropsychiatric disorders and cognitive impairment. TBI, even mild brain injury, has also been recognized as a significant risk factor for the later development of dementia and Alzheimer's disease. Although the link between TBI and dementia is currently unknown, several proposed mechanisms have been put forward, including alterations in glucose metabolism, excitotoxicity, calcium influx, mitochondrial dysfunction, oxidative stress, and neuroinflammation. A treatment for the devastating long-term consequences of TBI is desperately needed. Unfortunately, however, no such treatment is currently available, making this a major area of unmet medical need. Increasing the level of neurotrophic factor expression in key brain areas may be one potential therapeutic strategy. Of the neurotrophic factors, granulocyte-colony stimulating factor (G-CSF) may be particularly effective for preventing the emergence of long-term complications of TBI, including dementia, because of its ability to reduce apoptosis, stimulate neurogenesis, and increase neuroplasticity.

Twelve-month recovery of medical decision-making capacity following traumatic brain injury

OBJECTIVE

To investigate recovery of medical decision-making capacity (MDC) over the first year following traumatic brain injury (TBI).

METHODS

A total of 177 participants (111 persons with TBI and 66 healthy controls) were recruited from an inpatient/outpatient TBI rehabilitation unit and outpatient neurology department. Participants with TBI were classified by injury severity into subgroups: mild TBI (mTBI; n = 28), complicated mild TBI (cmTBI; n = 23), and moderate/severe TBI (msevTBI; n = 60). Control and TBI groups were compared at 1 month (t1), 6 months (t2), and 12 months (t3) postinjury using the Capacity to Consent to Treatment Instrument (CCTI), which evaluates MDC using 5 consent standards: expressing choice, reasonable choice, appreciation, reasoning, and understanding.

RESULTS

Relative to controls, no TBI group displayed impairment on CCTI expressing choice or reasonable choice at any timepoint. Those with mTBI had reduced appreciation and understanding at t1, which resolved by t2. The cmTBI and msevTBI groups were impaired on all 3 complex consent standards at t1. While patients with cmTBI improved to a level similar to controls by t3, those with msevTBI remained impaired on reasoning and understanding. Across all TBI groups, notable MDC improvement only occurred over the first 6 months postinjury.

CONCLUSIONS

Over 1 year, most individuals with mTBI or cmTBI regain MDC, while many individuals with msevTBI have lingering deficits in reasoning and comprehension of treatment information. Clinical recovery of MDC occurs primarily during the first 6 months post-TBI regardless of injury severity. Clinicians can therefore identify MDC outcomes in TBI at 6 months postinjury.

Developing a Cognition Endpoint for Traumatic Brain Injury Clinical Trials

Cognitive impairment is a core clinical feature of traumatic brain injury (TBI). After TBI, cognition is a key determinant of post-injury productivity, outcome, and quality of life. As a final common pathway of diverse molecular and microstructural TBI mechanisms, cognition is an ideal endpoint in clinical trials involving many candidate drugs and nonpharmacological interventions. Cognition can be reliably measured with performance-based neuropsychological tests that have greater granularity than crude rating scales, such as the Glasgow Outcome Scale-Extended, which remain the standard for clinical trials. Remarkably, however, there is no well-defined, widely accepted, and validated cognition endpoint for TBI clinical trials. A single cognition endpoint that has excellent measurement precision across a wide functional range and is sensitive to the detection of small improvements (and declines) in cognitive functioning would enhance the power and precision of TBI clinical trials and accelerate drug development research. We outline methodologies for deriving a cognition composite score and a research program for validation. Finally, we discuss regulatory issues and the limitations of a cognition endpoint.

Neuropsychological functioning in a national cohort of severe traumatic brain injury: demographic and acute injury-related predictors

OBJECTIVES

To determine the rates of cognitive impairment 1 year after severe traumatic brain injury (TBI) and to examine the influence of demographic, injury severity, rehabilitation, and subacute functional outcomes on cognitive outcomes 1 year after severe TBI.

SETTING

National multicenter cohort study over 2 years.

PARTICIPANTS

Patients (N = 105), aged 16 years or older, with Glasgow Coma Scale score of 3 to 8 and Galveston Orientation and Amnesia Test score of more than 75.

MAIN MEASURES

Neuropsychological tests representing cognitive domains of Executive Functions, Processing Speed, and Memory. Injury severity included Rotterdam computed tomography score, Glasgow Coma Scale score, and posttraumatic amnesia (PTA) duration, together with length of rehabilitation and Glasgow Outcome Scale-Extended score.

RESULTS

In total, 67% of patients with severe TBI had cognitive impairment. Executive Functions, Processing Speed, and Memory were impaired in 41%, 58%, and 57% of patients, respectively. Using multiple regression analysis, Processing Speed was significantly related to PTA duration, Glasgow Outcome Scale-Extended score, and length of inpatient rehabilitation (R = 0.30); Memory was significantly related to Glasgow Outcome Scale-Extended score (R = 0.15); and Executive Functions to PTA duration (R = 0.10). Rotterdam computed tomography and Glasgow Coma Scale scores were not associated with cognitive functioning at 1 year postinjury.

CONCLUSION

Findings highlight cognitive consequences of severe TBI, with nearly two-thirds of patients showing cognitive impairments in at least 1 of 3 cognitive domains. Regarding injury severity predictors, only PTA duration was related to cognitive functioning.

Insomnia symptoms and behavioural health symptoms in veterans 1 year after traumatic brain injury

OBJECTIVE

Insomnia and behavioural health symptoms 1 year after traumatic brain injury (TBI) were examined in a clinical sample representative of veterans who received inpatient treatment for TBI-related issues within the Veterans Health Administration.

METHODS

This was a cross-sectional sub-study (n = 112) of the Polytrauma Rehabilitation Centres' traumatic brain injury model system programme. Prevalence estimates of insomnia, depression, general anxiety, nightmares, headache and substance use, stratified by injury severity, were derived. Univariate logistic regression was used to examine unadjusted effects for each behavioural health problem and insomnia by injury severity.

RESULTS

Participants were primarily male, < 30 years old and high school educated. Twenty-nine per cent met study criteria for insomnia; those with mild TBI were significantly more likely to meet criteria (43%) than those with moderate/severe TBI (22%), χ(2)(1, n = 112) = 5.088, p ≤ 0.05. Univariable logistic regression analyses revealed depressive symptoms and general anxiety were significantly associated with insomnia symptoms after TBI of any severity. Headache and binge drinking were significantly inversely related to insomnia symptoms after moderate/severe TBI, but not MTBI.

CONCLUSIONS

Veterans with history of TBI, of any severity, and current insomnia symptoms may be at increased risk for depression and anxiety 1 year after TBI.

Cognitive changes and dementia risk after traumatic brain injury: implications for aging military personnel

Traumatic brain injury (TBI) is recognized as an important risk factor for the long-term cognitive health of military personnel, particularly in light of growing evidence that TBI increases risk for Alzheimer's disease and other dementias. In this article, we review the neurocognitive and neuropathologic changes after TBI with particular focus on the potential risk for cognitive decline across the life span in military service members. Implications for monitoring and surveillance of cognition in the aging military population are discussed. Additional studies are needed to clarify the factors that increase risk for later life cognitive decline, define the mechanistic link between these factors and dementia, and provide empirically supported interventions to mitigate the impact of TBI on cognition across the life span.

Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury

OBJECTIVE

To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission.

DESIGN

Retrospective study.

SETTING

Rehabilitation center.

PARTICIPANTS

From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Recovery of consciousness and the FIM instrument.

RESULTS

Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology.

CONCLUSIONS

Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

The changing "epidemiology" of pediatric head injury and its impact on the daily clinical practice

AIM

This article focuses on the developments that occurred during the last two decades in the management of pediatric head injury. It describes the changes in incidence, various advancements in diagnosis, management, prognosis, prevention and strategies required for better outcome, and control of head injury.

MATERIALS AND METHODS

Thorough evaluation of various papers, research, and our experience revealed that in developed countries, there has been a decreasing trend in head trauma incidence and trauma-related deaths as compared to developing countries.

RESULTS

This is mainly attributed to the widespread implementation of preventive measures. The development in imaging facilities, better characterization and grading of severe trauma (see, for example, diffuse axonal injury), an advanced understanding of the pathophysiology of secondary brain injury, endocrinological disturbances, predictive factors of outcome, development in neurophysiological monitoring, management advances in critical care units, implementation of safely measures, etc. have brought a significant change in overall outcome and profile of pediatric head injury

CONCLUSION

The further developments in field of brain plasticity, stem cell, rehabilitation, evolution of new drugs, preventive community measures, and global policies to deal with head trauma are expected to play a major role in days to come. The development of future pediatric trauma centers based on current evolutions (in order to achieve a good outcome), global and emphatic preventions of trauma will be required to establish equilibrium between developed and developing countries.

Traumatic Brain Injury Model Systems of Care 2002-2007

During the years 2002 to 2007, 16 Traumatic Brain Injury Model Systems of Care (TBIMS) were funded by the National Institute on Disability and Rehabilitation Research to conduct site-specific and collaborative research projects, including contribution to a longitudinal database, within comprehensive systems of care specialized for people with traumatic brain injury. The TBIMS program has been in existence since 1987 and has undergone significant modifications over these years. Herein I provide an overview of the changes that occurred in the 2002-2007 funding cycle, the research initiatives that were carried out during that time, and brief descriptions of the 13 original TBIMS research articles included in this issue of Archives.