Comparison of Scoring Methods for the Participation Assessment With Recombined Tools–Objective

Predictors of Multidimensional Profiles of Participation After Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To identify personal, clinical, and environmental factors associated with 4 previously identified distinct multidimensional participation profiles of individuals following traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Participants ( n = 408) enrolled in the TBI Model Systems (TBIMS) Participation Module, all 1 year or more postinjury.

DESIGN

Secondary data analysis of cross-sectional data from participants in a multicenter TBIMS module study on participation conducted between May 2006 and September 2007. Participants provided responses to questionnaires via a telephone interview at their study follow-up (1, 2, 5, 10, or 15 years postinjury).

MAIN MEASURES

Participants provided responses to personal (eg, demographic), clinical (eg, function), environmental (eg, neighborhood type), and participation measures to create multidimensional participation profiles. Data from measures collected at the time of injury (preinjury questionnaire, injury characteristics) were also included. The primary outcome was assignment to one of 4 multidimensional participation profile groups based on participation frequency, importance, satisfaction, and enfranchisement. The measures used to develop the profiles were: Participation Assessment with Recombined Tools-Objective, Importance, and Satisfaction scores, each across 3 domains (Productivity, Social Relationships, Out and About in the Community) and the Enfranchisement Scale (contributing to one's community, feeling valued by the community, choice and control).

RESULTS

Results of the multinomial regression analysis, with 4 distinct participation profile groups as the outcome, indicated that education, current employment, current illicit drug use, current driving status, community type, and FIM Cognitive at follow-up significantly distinguished participation profile groups. Findings suggest a trend toward differences in participation profile groups by race/Hispanic ethnicity.

CONCLUSIONS

Understanding personal, clinical, and environmental factors associated with distinct participation outcome profiles following TBI may provide more personalized and nuanced guidance to inform rehabilitation intervention planning and/or ongoing clinical monitoring.

Cognitive Performance is Associated With 1-Year Participation and Life Satisfaction Outcomes: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To determine, in persons with traumatic brain injury (TBI), the association between cognitive change after inpatient rehabilitation discharge and 1-year participation and life satisfaction outcomes.

DESIGN

Secondary analysis of prospectively collected TBI Model Systems (TBIMS) data.

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

499 individuals with TBI requiring inpatient rehabilitation who completed the Brief Test of Adult Cognition by Telephone (BTACT) at inpatient rehabilitation discharge (ie, baseline) and 1-year postinjury.

MAIN OUTCOME MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS).

RESULTS

Of 2,840 TBIMS participants with baseline BTACT, 499 met inclusion criteria (mean [standard deviation] age = 45 [19] years; 72% male). Change in BTACT executive function (EF) was not associated with 1-year participation (PART-O; β = 0.087, 95% CI [-0.004, 0.178], P = .061) when it was the sole model predictor. Change in BTACT episodic memory (EM) was associated with 1-year participation (β = 0.096, [0.007, 0.184], P = .035), but not after adjusting for demographic, clinical, and functional status covariates (β = 0.067, 95% CI [-0.010, 0.145], P = .089). Change in BTACT EF was not associated with life satisfaction total scores (SWLS) when it was the sole model predictor (β = 0.091, 95% CI [-0.001, 0.182], P = .0503). Change in BTACT EM was associated with 1-year life satisfaction before (β = 0.114, 95% CI [0.025, 0.202], P = .012) and after adjusting for covariates (β = 0.103, [0.014, 0.191], P = .023). In secondary analyses, change in BTACT EF was associated with PART-O Social Relations and Out and About subdomains before (Social Relations: β = 0.127, 95% CI [0.036, 0.217], P = .006; Out and About: β = 0.141, 95% CI [0.051, 0.232], P = .002) and after (Social Relations: β = 0.168, 95% CI [0.072, 0.265], P < .002; Out and About: β = 0.156, 95% CI [0.061, 0.252], P < .002) adjusting for functional status and further adjusting for covariates (Social Relations: β = 0.127, 95% CI [0.040, 0.214], P = .004; Out and About: β = 0.136, 95% CI [0.043, 0.229], P = .004). However, only the models adjusting for functional status remained significant after multiple comparison correction (ie, Bonferroni-adjusted alpha level = 0.002).

CONCLUSION

EF gains during the first year after TBI were related to 1-year social and community participation. Gains in EM were associated with 1-year life satisfaction. These results highlight the potential benefit of cognitive rehabilitation after inpatient rehabilitation discharge and the need for interventions targeting specific cognitive functions that may contribute to participation and life satisfaction after TBI.

10-year variability in high and low life satisfaction trajectories post-traumatic brain injury: a TBI model systems study

PURPOSE

To determine how life satisfaction changes across the first 10 years following traumatic brain injury (TBI).

METHODS

Participants included 1,941 individuals from the TBI Model Systems database with life satisfaction data at 1-, 5-, and 10-years post-TBI. Based on Satisfaction With Life Scale scores, individuals were characterized as having one of the five 10-year life satisfaction trajectories: 'Stable High,' 'Stable Low,' 'Increased to High,' 'Decreased to Low,' and 'Unstable.' These were analyzed for group differences in demographics and psychosocial and functional outcomes.

RESULTS

Sixty percent participants had 'Stable High' or 'Increasing to High' trajectories. Approximately 25% had "Stable Low' or 'Decreasing to Low' trajectories, and approximately 15% had unstable trajectories. Higher life satisfaction trajectories were associated with the best psychosocial and functional outcomes whereas lower trajectories were associated with the worst psychosocial and functional outcomes. Trajectories were indistinguishable based on demographics.

CONCLUSION

Life satisfaction over the first 10 years following TBI is dynamic, with most individuals reporting high life satisfaction by 10 years post-TBI. Examination of psychosocial and functional factors related to life satisfaction trajectories may inform community-based intervention recommendations, resources, and supports to maximize long-term satisfaction with life.

Association Between Participation and Satisfaction With Life Over Time in Older Adults With Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVE

To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults.

SETTING

Community.

PARTICIPANTS

Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older.

DESIGN

Secondary data analysis of a large multicenter database.

MAIN MEASURES

Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS).

RESULTS

SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups.

CONCLUSIONS

These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important.

Factors related to social inferencing performance in moderate-severe, chronic TBI

OBJECTIVE

Following traumatic brain injury (TBI), deficits in social cognition are common. Social inferencing is a crucial component of social cognition that enables an individual to understand the thoughts, feelings, and intentions of a communication partner when this information is not explicitly stated. Existing literature suggests a variety of factors contribute to social inferencing success (e.g. biological sex, executive functioning), yet findings are not conclusive, largely because these factors have been examined in isolation.

METHOD

In this cross-sectional study, stepwise regression with cross validation was used to examine the extent that several theoretically motivated factors were associated with social inferencing (measured by performance on The Awareness of Social Inference Test [TASIT]) in adult participants with TBI (n = 105). Demographic information, executive functioning, aggression, emotional functioning measures, and participation in society were all examined in relation to social inferencing performance.

RESULTS

The findings confirm the importance of higher-level cognitive skills (i.e. executive functioning) in social inferencing, and advance the literature by underlining the potential importance of productive participation in social inferencing performance.

CONCLUSION

This study innovatively highlights factors linked with social inferencing skills and, in doing so, how deficits in social inferencing might manifest in the lives of individuals with TBI.

Developing multidimensional participation profiles after traumatic brain injury: a TBI model systems study

Purpose. To characterize societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions.Materials and Methods. We conducted secondary analyses of a TBI Model Systems sub-study (N = 408). Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1-15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis.Results. A 4-class solution was identified as providing maximal statistical separation between profiles and being clinically meaningful based on profile demographic features. One profile group (48.5% of the sample) exhibited the "best" participation profile (High Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles.Conclusions. Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. The use of participation profiles may promote precision health interventions for community integration.Implications for RehabilitationOur study found unidimensional measures of societal participation in traumatic brain injury (TBI) populations that focus exclusively on frequency indicators may be overly simplistic and miss key subjective components of participationTaking a multidimensional perspective, we documented four meaningfully distinct participation subgroups (including both objective and subjective dimensions of societal participation) within the TBI rehabilitation populationMultidimensional profiles of participation may be used to group individuals with TBI into target groups for intervention (e.g., deeper goal assessment for individuals who do not rate standard participation activities as important, but also do not participate and do not feel enfranchised).

Mood Tracker: A Randomized Controlled Trial of a Self-Monitoring Intervention for Emotional Distress After Traumatic Brain Injury

OBJECTIVE

Persons with traumatic brain injury (TBI) frequently experience emotional distress (ED) manifested in anxiety and depression. However, they may not access mental health services due to external (eg, access, transportation, and cost) or internal (eg, stigma and discomfort with traditional counseling) barriers. Based on substantial literature indicating that self-monitoring can ameliorate several health conditions, we conducted a randomized, parallel group, wait-list control (WLC) trial of a self-monitoring intervention to decrease ED after TBI.

SETTING

Community in the southwestern United States.

PARTICIPANTS

Persons with medically documented complicated mild, moderate, and severe TBI.

DESIGN

About 127 participants were randomized in blocks of 6 to an active treatment (AT) group, wherein they completed multiple assessments of ED each week over a 6-week period via a smartphone app, or a WLC group in a parallel group, controlled trial. Participants received weekly support calls to promote self-monitoring of ED using ecological momentary assessment.

MAIN MEASURES

ED (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), Satisfaction with Life Scale, and Participation Assessment with Recombined Tools-Objective.

RESULTS

Analysis of the primary study outcome at 6 weeks after initiation of treatment for the AT group did not demonstrate that self-monitoring was effective in decreasing ED as compared to the WLC group. Brief support calls made weekly to promote compliance with self-monitoring were effective in achieving the target number of self-assessments. About 80% of support calls lasted less than 5 minutes. Greater ED was associated with lower life satisfaction and lower participation indicating the importance of addressing ED in persons with TBI.

CONCLUSION

Additional work is needed to develop nontraditional interventions to circumvent barriers that prevent persons with TBI from accessing care for ED. Brief support calls may be an effective, low-cost intervention to improve compliance with self-monitoring or self-management interventions.

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury

OBJECTIVES

To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI.

DESIGN

Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI.

MAIN MEASURES

Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40).

RESULTS

The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores.

CONCLUSIONS

Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability

PURPOSE

Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI.

MATERIALS AND METHODS

Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed.

RESULTS

The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain.

CONCLUSIONS

Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

LEVEL OF EVIDENCE: 4

The Participation Assessment with Recombined Tools-Objective (PART-O): measurement properties of the Norwegian version after traumatic brain injury

OBJECTIVE

To translate and evaluate the validity of the Participation Assessment with Recombined Tools-Objective (PART-O) in a Norwegian context.

METHODS

One hundred and twenty persons with TBI with verified intracranial lesions and persistent symptoms lasting more than 2 years, included in a randomized controlled trial, rated their participation using the PART-O at baseline. The PART-O with its three subscales (Productivity, Out and About, and Social Relations) was translated to Norwegian. Descriptive statistics, Cronbach's alpha, Rasch analysis, and correlation analysis were applied.

RESULTS

The Rasch analysis indicated a unidimensional construct of PART-O and its subscales (χ2 < 12.69, p > 0.28). The internal consistency was moderate (Cronbach's alpha 0.48-0.52) and there was a need to reduce scaling options for most of the items. The Out and About and Productivity subscales had considerable floor effects. PART-O showed moderate positive correlation to TBI-related quality of life and global functioning.

CONCLUSIONS

PART-O and its subscales reflect unidimensional aspects of participation. In the present Norwegian TBI population the original scaling of PART-O was too detailed for all subscales. The floor effects and suboptimal targeting between items and subjects participation level of the Out and About subscale is a matter of concern.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition).

DESIGN

This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review.

MAIN MEASURES

Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported).

RESULTS

Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors.

CONCLUSIONS

Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study

OBJECTIVE

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury.

PARTICIPANTS

Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC).

SETTING

Five VA PRCs.

DESIGN

Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study.

MAIN MEASURES

PART-O.

RESULTS

Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 .

CONCLUSION

Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Participation in the Chronic Phase after Traumatic Brain Injury: Variations and Key Predictors

Participation is of major importance for individuals with traumatic brain injury (TBI). This study evaluates participation over a period of one year among persons with TBI in the chronic phase and explores sociodemographic, psychological, and environmental predictors of levels and trajectories of participation. One hundred and twenty home-living survivors of TBI with persistent injury-related consequences at least two years post-injury who participated in a goal-oriented randomized trial were assessed at baseline and after four and twelve months. Linear mixed-effects model analysis was applied to evaluate height, trajectory slope, and predictors of the Participation Assessment with the Recombined Tools-Objective (PART-O) total score and the subscales Productivity, Social Relations, and Being Out and About. Being married, having a higher education, and having good global functioning predicted more frequent participation. Education, executive- and global functions predicted Productivity, while age and being married predicted Social Relations. Participating in the study during the COVID-19 pandemic had a negative impact on Productivity. Participation was relatively stable over 12 months, with a slight decline, but may be influenced by demographic factors and functional consequences. Rehabilitation services should particularly focus on people with TBI living alone with lower levels of global and executive function.

Effect of an Individually Tailored and Home-Based Intervention in the Chronic Phase of Traumatic Brain Injury: A Randomized Clinical Trial

Importance

Traumatic brain injury (TBI) can cause long-lasting and heterogeneous difficulties that require an individually tailored approach to rehabilitation. However, high-quality studies of treatment options in the chronic phase of TBI are lacking.

Objective

To evaluate the effect of a home-based, individualized, and goal-oriented rehabilitation intervention in the chronic phase of TBI.

Design, Setting, and Participants

This study was an intention-to-treat parallel-group assessor-blinded randomized clinical trial with 1:1 randomization to an intervention or control group. Participants included adults in southeastern Norway who had sustained a TBI more than 2 years earlier, lived at home, and had ongoing TBI-related difficulties. A population-based sample of 555 individuals were invited, and 120 were included. Participants were assessed at baseline, 4 months, and 12 months after inclusion. Specialized rehabilitation therapists provided the intervention in patients' homes or via video conference and telephone. Data collection was conducted between June 5, 2018, and December 14, 2021.

Interventions

The intervention group received an 8-session individually tailored and goal-oriented rehabilitation program over 4 months. The control group received usual care in their municipality.

Main Outcomes and Measures

Preestablished primary outcomes were disease-specific health-related quality of life (HRQOL; measured by the Quality of Life After Brain Injury [QOLIBRI] overall scale) and social participation (measured by the Participation Assessment With Recombined Tools-Objective [PART-O] social subscale). Preestablished secondary outcomes included generic HRQOL (measured by the EuroQol 5-dimension 5-level [EQ-5D-5L] questionnaire), difficulty with TBI-related problem management (target outcomes; mean severity calculated across 3 main self-identified problem areas that were individually measured using a 4-point Likert scale), TBI symptoms (measured by the Rivermead Post Concussion Symptoms Questionnaire [RPQ]), psychological distress (depression and anxiety; measured by the Patient Health Questionnaire 9-item scale and the Generalized Anxiety Disorder 7-item scale [GAD-7], respectively), and functional competency (measured by the Patient Competency Rating Scale).

Results

Among 120 participants in the chronic phase of TBI, the median (IQR) age was 47.5 (31.0-55.8) years, and the median (IQR) time since injury was 4 (3-6) years; 85 (70.8%) were male. A total of 60 participants were randomized to the intervention group, and 60 were randomized to the control group. Between baseline and 12 months, no significant between-group effects were found for the primary outcomes of disease-specific HRQOL (QOLIBRI overall scale score: 2.82; 97.5% CI, -3.23 to 8.88; P = .30) or social participation (PART-O social subscale score: 0.12; 97.5% CI, -0.14 to 0.38; P = .29). At 12 months, the intervention group (n = 57) had significantly higher generic HRQOL (EQ-5D-5L score: 0.05; 95% CI, 0.002-0.10; P = .04) and fewer symptoms of TBI (RPQ total score: -3.54; 95% CI, -6.94 to -0.14; P = .04) and anxiety (GAD-7 score: -1.39; 95% CI, -2.60 to -0.19; P = .02) compared with the control group (n = 55). At 4 months only, the intervention group (n = 59) had significantly less difficulty managing TBI-related problems (target outcomes mean severity score: -0.46, 95% CI, -0.76 to -0.15; P = .003) compared with the control group (n = 59). No adverse events were reported.

Conclusions and Relevance

In this study, no significant results were observed for the primary outcomes of disease-specific HRQOL or social participation. However, the intervention group reported improvements in secondary outcomes (generic HRQOL and symptoms of TBI and anxiety) that were maintained at 12-month follow-up. These findings suggest that rehabilitation interventions could help patients even in the chronic phase of TBI.

Trial Registration

ClinicalTrials.gov Identifier: NCT03545594.

Enhanced education for adult patients with persistent post-concussion headaches: a randomized controlled trial

Aim & Patients

We conducted a randomized clinical trial to determine if an e-learning intervention can enhance recovery in adult patients with persistent post-concussion headaches (PPCH).

Materials & Methods

The intervention consisted of three e-learning modules administered at baseline, 6 and 12 weeks. Data were collected on symptoms, community integration, quality of life and healthcare utilization at baseline and 12-week follow-up. ANCOVA was conducted to compare changes.

Results

No statistically significant difference was observed on symptoms although we observed a trend toward reduced healthcare utilization and improved quality of life in the intervention group.

Conclusion

E-learning modules for patients experiencing PPCH warrant further investigation with data on participant compliance and measures focusing on simpler short-term outcomes.Clinical Trial Registration: NCT03391583 (ClinicalTrials.gov).

A Study Protocol for a Multisite Randomized Controlled Trial of an Intervention to Improve Outcomes After Spinal Cord Injury

Background

The consequences of spinal cord injury (SCI) can place significant demands on an individual's coping mechanisms. Interventions to promote psychological adjustment and coping are often included in inpatient rehabilitation programs; however, following discharge, many individuals with SCI do not receive ongoing counseling or education about psychological adjustment to disability. Effective postacute treatment models are needed to help individuals with SCI build skills that help them adapt to the stresses associated with a chronic physical disability, alleviate the consequences of anxiety and depression, and enhance subjective well-being.

Objectives

To describe the protocol for a randomized clinical trial (RCT) of a 6-week intervention designed to improve psychosocial outcomes after SCI.

Methods

To test efficacy and replicability of the intervention, we designed a three-arm, multisite RCT with assessments conducted at six time points. Our primary hypothesis is that participants in the Group arm will report greater improvements in psychosocial outcomes than participants who complete the intervention individually via video (Individual arm) or those who do not receive the intervention (Control arm). We also hypothesize that participants in the Group arm will maintain greater improvements in psychosocial outcomes longer than those in the individual or control arms.

Conclusion

Results of the RCT will be presented and published to professionals and consumers, and intervention training and materials will be made available upon request.

Patient-Reported Problem Areas in Chronic Traumatic Brain Injury

OBJECTIVE

The aims of this study were to (1) assess self-reported main problem areas reported by patients with traumatic brain injury (TBI) and their family members in the chronic phase, and (2) compare the self-prioritized problems with difficulties captured by questionnaires and neuropsychological screening through linking to the International Classification of Functioning, Disability and Health (ICF).

SETTING

Outpatient clinic at the Oslo University Hospital, Norway.

PARTICIPANTS

In total, 120 patients with TBI were recruited, of whom, 78 had a participating family member. Eligibility criteria were a clinical TBI diagnosis with verified intracranial injury, living at home, aged 18 to 72 years, 2 years or more postinjury, and experiencing perceived TBI-related difficulties, reduced physical and mental health, or difficulties with participation in everyday life. Patients with severe psychiatric or neurological disorders or inability to participate in goal-setting processes were excluded.

DESIGN

Cross-sectional.

MAIN MEASURES

Target Outcomes, that is, 3 main TBI-related problem areas reported by patients and family members, collected in a semistructured interview; standardized questionnaires of TBI-related symptoms, anxiety, depression, functioning, and health-related quality of life; neuropsychological screening battery.

RESULTS

Target Outcomes were related to cognitive, physical, emotional, and social difficulties. Target Outcomes were linked to 12 chapters and 112 distinct categories in the ICF, while standardized measures only covered 10 chapters and 28 categories. Some aspects of post-TBI adjustment were found to be insufficiently covered by the ICF classification, such as identity issues, lack of meaningful activities, and feeling lonely.

CONCLUSION

The Target Outcomes approach is a useful assessment method in a population with chronic TBI. The standardized questionnaires capture the spectrum of problems, whereas the Target Outcomes approach captures the prioritized individual problems hindering everyday life after TBI. While the standardized measures are an irreplaceable part of the assessment, Target Outcomes ensures patient involvement and may help clinicians better tailor relevant rehabilitation efforts.

Changes in social participation between 1 and 2 years following moderate-severe traumatic brain injury

Objective

To examine patterns of change in social participation in persons with moderate-severe traumatic brain injury (msTBI) between 1 and 2 years postinjury, and predictors of observed change.

Participants

375 participants with msTBI enrolled in a single TBI Model System site.

Measures and Methods

The dependent variable in a linear regression was a reliable change score for the Social Relations subscale of the Participation Assessment with Recombined Tools-Objective, administered at 1- and 2-year follow-ups. Predictors of change included demographics, injury severity, social and functional status at Year 1, and changes in function and life circumstances between years 1 and 2.

Results

Social participation status did not change substantially for 34 of the sample, while approximately equal proportions of the remainder improved or declined. The regression model was significant (p < 0.001). Improvement was predicted by private vs. public insurance and decline was predicted by a reduction in the FIM functional outcome measure from year 1 to year 2. Marginal predictors included education (higher levels predicting improvement) and year 1 marital status (single status predicting decline).

Conclusions

Longitudinal change in social participation in the chronic phase of msTBI deserves further study, with attention to resource limitations and the impact of changes in functional status.

Enhancing Self-Advocacy After Traumatic Brain Injury: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of a novel intervention aimed at enhancing self-advocacy in individuals living with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Sixty-seven (35 allocated to treatment, 32 to control) community-dwelling adults 9 months or more post-TBI (mean of 8.9 years postinjury); previously discharged from inpatient or outpatient TBI rehabilitation; able to travel independently in the community, indicating a level of independence needed to engage in self-advocacy.

DESIGN

Longitudinal randomized 2-arm controlled trial (NCT no. 03385824). Computer-generated block randomization allocated participants to treatment/intervention or control/no-intervention. All outcome assessments completed by blinded study staff.

INTERVENTION

A manualized group intervention, Self-Advocacy for Independent Life (SAIL), addressing the self-efficacy beliefs, knowledge, and skills for self-advocacy following TBI.

MAIN OUTCOME MEASURES

The Self-Advocacy Scale (SAS) (primary); General Self-Efficacy Scale (GSE); Personal Advocacy Activity Scale (PAAS); Satisfaction With Life Scale (SWLS).

RESULTS

The treatment group showed significantly greater improvement than controls from baseline to posttreatment on the primary measure (SAS) of self-efficacy specific to self-advocacy after TBI (effect size = 0.22). Similar improvements were found on secondary measures of general self-efficacy and satisfaction with life from baseline to posttreatment. However, significant between-groups gains for primary and secondary measures were not maintained over 6- and 12-week follow-up.

CONCLUSIONS

Individuals living with chronic TBI sequelae can increase self-efficacy specific to self-advocacy, general self-efficacy, and satisfaction with life, through a TBI-specific intervention aimed at empowering individuals to advocate for their own needs and wishes. Sustaining gains over time may require ongoing community collaboration and support. This could involve community-based systems of self-advocacy education, resources, and peer support.

Participation Predicts Cognitive Functioning in Older Adults Using the PART-O Transformed Scores Systems

Participation has been shown to be a protective factor for cognition in older adults, but instruments to assess it are limited. The main objective was to determine the validity of two scoring systems (direct vs transformed) for the Participation Assessment with Recombined Tools-Objective (PART-O) by applying structural equation modeling to the relationship between the subscales and the cognitive functions, in a sample of 245 people over 60 years of age. The transformed scores model showed stronger relationships and larger explained variance in overall participation (55.4% vs 37.4%), especially in the Social Relations subscale (31.4% vs 14.6%). Participation was a direct predictor of cognitive functions in both models. Age and depression inversely influenced participation in the transformed scores model. The proposed score transformation for the PART-O provides a more appropriate measurement of the older adults' participation. Participation has a mediating role in the relationship between cognition and both age and depression.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years).

DESIGN

Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations.

RESULTS

Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites.

CONCLUSIONS

The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Do state supports for persons with brain injury affect outcomes in the 5 Years following acute rehabilitation?

While a substantial literature has examined the effects of individual and family-level factors on outcomes following traumatic brain injury (TBI), minimal attention has been directed to the potential influence of the larger environmental context on outcomes. The purpose of the current study was to investigate the effects of state-level resources and supports as an environmental factor influencing long-term outcomes from TBI using data from the TBI Model Systems. We examined the effects of U.S. state supports that specifically target people with TBI (federal funding for state brain injury programs, per capita revenue generated by brain injury trust funds, and expenditures for brain injury specific Medicaid waivers) and one measure of the relative quality of a state's Long-Term Services and Supports (LTSS) for all people with disabilities. The primary hypothesis was that community participation, global functioning, and life satisfaction will be higher on average among people with TBI living in states with more brain injury specific programs and resources and better LTSS. The results of multilevel and fixed-effects modeling indicated that state supports have a small but significant impact on participation and life satisfaction. The most consistent finding indicated that states with better LTSS had higher levels of community participation and life satisfaction on average for people with TBI over and above individual-level differences and fluctuations in these outcomes over time. There was some indication that more brain injury specific supports also result in better participation in the community. These findings deserve replication and extension to include other environmental factors, particularly community level characteristics, that might affect outcomes from TBI.

Quasi-Contextualized Speech Treatment in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge

OBJECTIVE

To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation.

DESIGN

Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9.

RESULTS

When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment.

CONCLUSIONS

The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Refining understanding of life satisfaction in elderly persons with traumatic brain injury using age-defined cohorts: a TBI model systems study

OBJECTIVE

Examine effects of age cohort on post-injury life satisfaction in elderly persons with TBIDesign: Retrospective cohortSetting: TBI Model Systems centers.

PARTICIPANTS

5,109 elderly participants with TBI in the TBI Model Systems National DatabaseInterventions: Not applicableMain Outcome Measures: Demographics, injury characteristics and cause, outcomes, age at time of analysis, time to follow commands, maximum follow-up period, and scores on the Satisfaction With Life Scale (SWLS) and Participation Assessment with Recombined Tools-Objective (PART-O) scores at 1, 2, 5, or 10 years post-injury.

RESULTS

Life satisfaction post-TBI across groups increased with age. The young-old sub-group demonstrated the poorest life satisfaction outcomes, while the oldest sub-group experienced greatest life satisfaction. In contrast, participation decreased with age.

CONCLUSIONS

Findings show diversity in satisfaction with life following moderate to severe TBI for three elderly age-cohorts. Differences may be due to variations in generation-based lived experience, in perceived meaningfulness of participation, could echo prior evidence of greater resilience in the oldest group, or could reflect bias within the study sample. Further research into between- and within- differences for elderly TBI age cohorts is needed to more precisely meet their needs for physical and functional rehabilitation as well as psychological supports.

Primary Language and Participation Outcomes in Hispanics With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine the relationship between primary language and participation outcomes in English- and Spanish-speaking persons with complicated mild to severe traumatic brain injury (TBI) at 1 year post-injury.

SETTING

Community following discharge from inpatient rehabilitation.

PARTICIPANTS

A total of 998 Hispanic participants with outcomes available at year 1 follow-up; 492 (49%) indicated English as their primary language and 506 (51%) indicated Spanish as their primary language.

DESIGN

Prospective, multicenter, cross-sectional, observational cohort study.

MAIN MEASURES

Community participation at 1 year post-injury was assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out and About, Productivity, and Social Relations.

RESULTS

Unadjusted group comparisons showed better participation outcomes for English versus Spanish speakers for all PART-O domains and for the Balanced Total score. After controlling for relevant covariates, English-speaking participants had significantly better PART-O Balanced Total scores and better scores on the Social Relations domain, although effect sizes were small.

CONCLUSIONS

Hispanic persons with TBI whose primary language is Spanish may require greater assistance integrating socially back into their communities after TBI. However, potential cultural differences in value placed on various social activities must be considered. Potential cultural bias inherent in existing measures of participation should be investigated in future studies.

Smartphone Application for Measuring Community Participation in Veterans With Traumatic Brain Injury

The goal in the rehabilitation of veterans with mild traumatic brain injury (mTBI) is to improve community participation. A tool that can objectively measure community participation is lacking. The aims of this study are to evaluate the feasibility of a smartphone application (app) called MOVES to objectively measure community participation; and compare MOVES with a self-report questionnaire, and differences between veterans with mTBI and civilians without TBI. It is a 6-week parallel observational study, which included seven veterans with blast-related mTBI and five civilians without TBI. The measures include MOVES, Participation Assessment with Recombined Tools-Objective (self-report participation measure), Satisfaction Questionnaire, and Perceived Accuracy Daily Logs. Participants were mostly satisfied using the MOVES app with 75% retention rate. Perceived accuracy of the MOVES app was 90%, while the two groups showed similar discrepancies between the PART-O and the MOVES (52% vs. 53%). The MOVES app is a feasible option to objectively measure community participation. Self-report was discrepant from the MOVES app for both groups.

Negative Attribution Bias and Related Risk Factors After Brain Injury

OBJECTIVE

In participants with traumatic brain injury (TBI) and peer controls, examine (1) differences in negative attributions (interpret ambiguous behaviors negatively); (2) cognitive and emotional factors associated with negative attributions; and (3) negative attribution associations with anger responses, life satisfaction, and participation.

SETTING

Two TBI outpatient rehabilitation centers.

PARTICIPANTS

Participants with complicated mild to severe TBI (n = 105) and peer controls (n = 105).

DESIGN

Cross-sectional survey study.

MAIN MEASURES

Hypothetical scenarios describing ambiguous behaviors were used to assess situational anger and attributions of intent, hostility, and blame. Executive functioning, perspective taking, emotion perception and social inference, alexithymia, aggression, anxiety, depression, participation, and life satisfaction were also assessed.

RESULTS

Compared with peer controls, participants with TBI rated behaviors significantly more intentional, hostile, and blameworthy. Regression models explained a significant amount of attribution variance (25%-43%). Aggression was a significant predictor in all models; social inference was also a significant predictor of intent and hostility attributions. Negative attributions were associated with anger responses and lower life satisfaction.

CONCLUSION

People with TBI who have higher trait aggression and poor social inferencing skills may be prone to negative interpretations of people's ambiguous actions. Negative attributions and social inferencing skills should be considered when treating anger problems after TBI.

Evaluating the Cross-Sectional and Longitudinal Relationships Predicting Suicidal Ideation Following Traumatic Brain Injury

OBJECTIVE

Characterize relationships among substance misuse, depression, employment, and suicidal ideation (SI) following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Inpatient rehabilitation centers with telephone follow-up; level I/II trauma centers in the United States.

PARTICIPANTS

Individuals with moderate to severe TBI with data in both the National Trauma Data Bank and the Traumatic Brain Injury Model Systems National Database, aged 18 to 59 years, with SI data at year 1 or year 2 postinjury (N = 1377).

MAIN OUTCOME MEASURE

Primary outcome of SI, with secondary employment, substance misuse, and depression outcomes at years 1 and 2 postinjury.

RESULTS

Cross-lagged structural equation modeling analysis showed that year 1 unemployment and substance misuse were associated with a higher prevalence of year 1 depression. Depression was associated with concurrent SI at years 1 and 2. Older adults and women had a greater likelihood of year 1 depression. More severe overall injury (injury severity score) was associated with a greater likelihood of year 1 SI, and year 1 SI was associated with a greater likelihood of year 2 SI.

CONCLUSIONS

Substance misuse, unemployment, depression, and greater extracranial injury burden independently contributed to year 1 SI; in turn, year 1 SI and year 2 depression contributed to year 2 SI. Older age and female sex were associated with year 1 depression. Understanding and mitigating these risk factors are crucial for effectively managing post-TBI SI to prevent postinjury suicide.

Unmet Rehabilitation Needs Indirectly Influence Life Satisfaction 5 Years After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).

DESIGN

Prospective observational cohort.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction With Life Scale (SWLS).

RESULTS

Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.

CONCLUSIONS

Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Heterogeneity in Temporal Ordering of Depression and Participation After Traumatic Brain Injury

OBJECTIVE

To examine heterogeneity in the temporal patterns of depression and participation over the first 2 years post traumatic brain injury (TBI).

DESIGN

Observational prospective longitudinal study.

SETTING

Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone.

PARTICIPANTS

Persons with TBI (N=2307) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years post injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 (PHQ-9) and Participation Assessment With Recombined Tools-Objective (PART-O).

RESULTS

Using latent class modeling we examined heterogeneity in the longitudinal relationship between PHQ-9 and PART-O. The identified 6 classes were most distinct in terms of (1) level of PHQ-9 score and (2) association between the year 1 PART-O score and year 2 PHQ-9 score. For most participants, PART-O at year 1 predicted PHQ-9 at year 2 more than the reverse. However, there was a subgroup of participants that demonstrated the reverse pattern, PHQ-9 predicting later PART-O, who were on average, older and in the "other" employment category.

CONCLUSIONS

Results suggest that links between participation and depression are stronger for some people living with TBI than for others and that variation in the temporal sequencing of these 2 constructs is associated with demographic characteristics. These findings illustrate the value in accounting for population heterogeneity when evaluating temporal among outcome domains.

A randomized controlled trial of acceptance and commitment therapy for psychological distress among persons with traumatic brain injury

Psychological distress is common in persons with traumatic brain injury (TBI) but treatments remain underdeveloped. This randomized controlled trial of Acceptance and Commitment Therapy (ACT) was designed to address this gap. Ninety-three persons with medically-documented complicated mild to severe TBI, normal-to-mildly impaired memory, and clinically significant psychological distress in the chronic phase of recovery were randomized to receive eight weeks of ACT (manualized with adaptations to address TBI-related cognitive impairments) or a single session of needs assessment, brief counseling/education, and referral. The ACT group showed significantly greater reduction of psychological distress (Brief Symptom Inventory 18) and demonstrated improvements in psychological flexibility and commitment to action (Acceptance and Action Questionnaire-II (AAQ-II) scores). The number of treatment responders (post-treatment BSI 18 GSI T scores <63) was larger in the ACT group than in the control group. Entry of AAQ-II scores into the model of between-group differences in BSI 18 GSI T scores indicated that core ACT processes explained the variance in treatment group outcomes. Provision of ACT reduces psychological distress in persons with TBI in the chronic phase of recovery when adaptations are made to accommodate TBI-related cognitive impairments. Additional clinical trials with a structurally equivalent control group are needed.

Traumatic brain injury-needs and treatment options in the chronic phase: Study protocol for a randomized controlled community-based intervention

BACKGROUND

Traumatic brain injury (TBI) is often associated with life-long medical, cognitive, emotional, and behavioral changes. Although long-lasting disabilities are expected, research on effective treatment options in the chronic phase of TBI is scarce.

METHODS/DESIGN

This study protocol describes a randomized controlled trial (RCT) aimed at evaluating the effectiveness of a goal-oriented and community-based intervention for increasing community integration, quality of life, and functional independence in the chronic phase of complicated mild to severe TBI. Participants will be recruited from Oslo University Hospital, Norway. Patients aged 18-72 years living at home with MRI/CT-verified intracranial abnormalities, a TBI diagnosis, a time since injury of ≥ 2 years, and who experience either current TBI-related problems or restrictions in community integration will be included. The 120 participants will be randomized 1:1 to either (a) an intervention group, which will receive an in-home intervention program over 4 months, or (b) a control group receiving standard care in the municipalities. The intervention will consist of six home visits and two telephone contacts with a rehabilitation professional. A SMART-goal approach will be adopted to target the individual's self-reported TBI difficulties in everyday life. Primary outcomes will be self-reported quality of life and participation. Secondary outcomes include symptom burden, emotional functioning, and clinician-assessed global outcome and need for rehabilitation services. Outcomes will be evaluated at baseline and 4-5 and 12 months after baseline. Caregiver burden and general health will be assessed in participating family members. Goal attainment and acceptability will be evaluated in the intervention group. A process evaluation will be carried out to evaluate protocol adherence, and a cost-effectiveness analysis will be applied if the intervention is found to be effective.

DISCUSSION

The current study provides an innovative approach to rehabilitation in the chronic phase of TBI evaluated using an RCT design that may inform treatment planning, health policies, and coordination of patient care. Further, the study may demonstrate new modes of establishing collaboration and knowledge transition between specialized rehabilitation facilities and local rehabilitation services that may improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545594. Registered on June 4th, 2018.

Participation differences by age and depression 5 years after moderate-to-severe traumatic brain injury

Participation restrictions, including restrictions in employment, recreational activities, and social interactions, and depression are common after traumatic brain injury (TBI) and can profoundly affect individuals. Participation and depression demonstrate complex relationships with each other and over time as individuals age. This study (1) identified differences in participation between different age groups; (2) determined if participation differed between those with and without clinically significant depressive symptoms within each age group; and (3) determined the effect of the interaction between age groups and the presence or absence of clinically significant depressive symptoms on participation in community-dwelling adults with a moderate-to-severe TBI. Results indicate that, among community-dwelling adults 5 years post-TBI, there are significant differences in participation between age groups across the lifespan, with younger adults generally having higher levels of participation. Individuals with clinically significant depressive symptoms participate less than individuals without it within the same age group, except for adults over 65 years-old. For the productivity domain, age interacted with depressive symptoms, such that the presence of clinically significant depressive symptoms was associated with a larger difference in productivity in early-to-middle adulthood. Based on these findings, depression should be considered when providing interventions for participation and vice versa.

Participation Following Inpatient Rehabilitation for Traumatic Disorders of Consciousness: A TBI Model Systems Study

Severe traumatic brain injury (TBI) may result in a disorder of consciousness (DoC) and lead to substantial long-term disability. While level of independence with activities of daily living, especially for persons who recover consciousness during inpatient rehabilitation, generally improves over time, the degree of change in participation remains unknown. We determined level of participation among persons with TBI between 2005 and 2017 who were admitted to inpatient rehabilitation unable to follow commands and subsequently enrolled in the TBI Model Systems National Database. Participation on the Participation Assessment with Recombined Tools-Objective (PART-O) Productivity, Social Relations, and Out and About subscales was evaluated at 1-5 years post-injury. We used a mixed-effects model to longitudinally compare participation between persons who did and did not regain command-following during inpatient rehabilitation. We further explored the level of participation associated with increasing levels of functional independence (FIM). The analysis included 333 persons (229 recovered command-following during rehabilitation, mean age = 35.46 years, 74.9% male). Participation across groups, at all follow-up time points, on all PART-O subscales, was remarkably low (mean range = 0.021-1.91, maximum possible score = 5). Performance was highest on the Social Relations subscale and lowest on the Productivity subscale. Longitudinal analyses revealed no difference in level of participation or change in participation across time for persons who regained command-following during rehabilitation compared to those who did not. While productivity increased over time, social participation did not and participation outside the home increased more for younger than for older persons. Across all three PART-O subscales, FIM Motor scores positively predicted participation. FIM Cognitive scores positively predicted level of participation on the Productivity and Social Relations subscales. Exploratory analyses revealed that even persons who achieved independence on the FIM Motor and Cognitive subscales had low levels of participation across domains and follow-up years. In summary, persons with severe TBI who were admitted to inpatient rehabilitation unable to follow commands were found to be unlikely to participate in productive tasks, social endeavors, or activities outside of the home up to 5 years post-injury, even if functional independence was recovered.

Volunteering and its association with participation and life satisfaction following traumatic brain injury

Background: Volunteering has been found to improve life satisfaction and participation in the general population, but its impact has not been thoroughly studied among those with traumatic brain injury (TBI). It is important to investigate whether volunteering is helpful in addressing participation and life satisfaction to inform future treatment.Objective: To characterize those who volunteer after moderate-severe TBI and to investigate the association of volunteering with participation and life satisfaction after TBI.Methods: Using data from a single site contributing to the TBI Model Systems National Database, a retrospective analysis of 725 individuals with TBI was conducted. General Linear Models were used to compare outcomes of those who volunteer and those who do not after controlling for important covariates.Results: Volunteers were more likely to be employed/students, have better current functioning, be further post-injury, non-Hispanic white, and have more education. Significant relationships, after controlling for covariates, were found between volunteering and higher life satisfaction, more frequent community engagement, and greater social relations. No significant relationship between volunteering and productivity emerged.Conclusions: Given the positive relationship between volunteer status with life satisfaction and aspects of participation, future research should investigate the barriers/facilitators of volunteering to improve well-being and participation after TBI.

Behavioral Activation Augmented With Mobile Technology for Depression and Anxiety in Chronic Moderate-Severe Traumatic Brain Injury: Protocol for a Randomized Controlled Trial

Objective

To describe and provide the rationale for a randomized controlled trial for depression or anxiety after moderate to severe traumatic brain injury (TBI), which will test 2 treatments based on behavioral activation (BA), a promising model to promote both positive mood and increased activity in this population.

Design

Randomized controlled trial with masked outcome assessment.

Setting

Outpatient catchment area of 1 TBI treatment center.

Participants

Community-dwelling persons (N=60) with moderate-severe TBI at least 6 months prior to enrollment and greater than mild depression or anxiety.

Interventions

Participants will be randomized 2:1 into an 8-session treatment, behavioral activation with technology, consisting of 6 face-to-face sessions and 2 via phone, with mood and activity monitoring conducted via ecological momentary assessment on a smartphone; or a single session incorporating BA principles followed by 8 weeks of activity reminders in the form of implementation intentions, delivered as text messages.

Main Outcome Measures

Brief Symptom Inventory-18 (primary outcome); Environmental Reward Observation Scale, Behavioral Activation for Depression Scale, Participation Assessment with Recombined Tools-Objective, Diener Satisfaction With Life Scale, Quality of Life after Brain Injury scale, Patient Global Impression of Change. Outcomes are measured midway through intervention, after treatment cessation (primary outcome), and at 2-month follow-up. A treatment enactment interview is administered after the follow-up to ascertain to what extent participants continue to engage in activities and use strategies promoted during trial participation.

Results

N/A.

Conclusions

N/A.

Transforming a Traumatic Brain Injury Measure of Participation Into a Psychometrically Sound Spinal Cord Injury Participation Measure

OBJECTIVE

To evaluate the use of Participation Assessment with Recombined Tools-Objective (PART-O) in spinal cord injury (SCI) and compare it with the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF).

DESIGN

Follow-up survey of inception cohort.

SETTING

Community.

PARTICIPANTS

Individuals with SCI, rehabilitated at 2 large SCI Model Systems and enrolled in the SCI Model Systems National Database, who were due for routine follow-up (N=468; median age at injury, 29; median time post injury, 5 years).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PART-O and CHART-SF.

RESULTS

Use of Rasch analysis identified an SCI-specific scoring of PART-O that demonstrated unidimensionality (first contrast eigenvalue of 1.76) with no misfitting items or disordered steps in any response categories. Person separation and reliability were 2.00 and .80, respectively. Unlike CHART-SF, PART-O had a relatively normal distribution with no floor or ceiling effects. Test-retest reliability PART-O administered 2-4 weeks apart was 0.97, with a reliable change index of 3.1 points on a 100-point scale. PART-O correlated 0.79 with the sum of 3 CHART-SF domains with similar content. The PART-O scoring was initially validated on a second data set.

CONCLUSIONS

PART-O can be used successfully to measure participation in a population of people with SCI. A new method of scoring PART-O in SCI provides an initially validated, univariate interval measure of participation with good psychometric properties that has advantages over the CHART-SF legacy measure of participation.

Predicting the Trajectory of Participation After Traumatic Brain Injury: A Longitudinal Analysis

OBJECTIVE

To identify factors that predict trajectories of participation over the first 5 years after moderate to severe traumatic brain injury (TBI).

SETTING

TBI Model System Programs.

PARTICIPANTS

Community-dwelling individuals with TBI, 16 years of age or older (n = 1947).

DESIGN

Secondary analysis of a prospective, nonrandomly sampled, longitudinal data registry.

MAIN MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

Age at injury and FIM Motor score predicted trajectory of participation over the first 5 years after moderate to severe TBI. Older age predicted generally worse participation overall as well as progressively worsening participation over time. Higher FIM Motor raised the predicted participation values, although it reduced the rate of improvement in participation scores over time. FIM Cognitive scores, race, depression, years of education, and living setting did not predict trajectory but did significantly influence participation consistently at all time points.

CONCLUSION

The trajectories of participation over the first 5 years after TBI can be predicted by age at injury and FIM Motor scores. These findings may enhance the ability of rehabilitation professionals to identify individuals at risk for poor participation after TBI and develop targeted interventions for optimizing involvement in life activities.

Characterizing computer-mediated communication, friendship, and social participation in adults with traumatic brain injury

BACKGROUND

Adults with traumatic brain injury (TBI) report loss of friendship and reduced social participation after injury, but there is limited information regarding quantity of friends and methods of communication. Our objective was to characterize friendship networks, social participation, and methods of communication, including computer-mediated communication (CMC), used by adults with TBI compared to uninjured adults.

METHODS

Participants were 25 adults with TBI and 26 uninjured healthy comparisons (HC) adults, who completed the Participation Assessment with Recombined Tools-Objective (PART-O) and the Social Network Questionnaire (SNQ).

RESULTS

Adults with TBI had significantly fewer total friends and significantly lower levels of productivity and overall social participation. Face-to-face interaction was the preferred method of contact for both groups. Adults with TBI were significantly less likely to use texting as a primary method of communication than their uninjured peers, but used other methods of communication at similar rates.

CONCLUSION

Our study supports prior findings of reduced friendships and reduced social participation after TBI and adds new information about similarities and differences in communication methods between adults with and without TBI.

Re-inventing yourself after spinal cord injury: a site-specific randomized clinical trial

Study Design:

Parallel-arm randomized controlled trial comparing an interactive group format versus a no-intervention control.

Objective:

To evaluate the efficacy of a replicable group treatment program for improving self-efficacy after spinal cord injury (SCI) in a single center cohort of adults.

Setting:

Regional SCI center.

Methods:

Participants included 81 individuals with SCI who were at least 4 weeks post-discharge from initial rehabilitation. Those randomized to treatment participated in six interactive learning sessions (2 hours each, one session per week) with structured and facilitated group interactions to improve self-efficacy. A wait-list control group was followed at matching time points for all outcome measures. The primary outcome measure was the Moorong Self-Efficacy Scale (MSES); secondary outcomes were the Generalized Self-Efficacy Scale (GSES); Diener Satisfaction with Life Scale (SWLS); Participation Assessment with Recombined Tools – Objective (PART-O); Patient Health Questionnaire – 9 (PHQ-9); and General Anxiety Disorder 7-item (GAD-7).

Results:

Individuals in the Treatment group had greater increases in MSES scores from baseline to immediately post-intervention (6 weeks) than the Control group, but that difference did not remain significant after controlling for multiple comparisons. However the improvement in the treatment group relative to the control group was not maintained through follow-up at 30 weeks. There was no evidence of an immediate or sustained treatment effect on any of the secondary outcomes.

Conclusions:

Self-efficacy improved for participants with SCI in the Treatment group, however, this improvement was not significant or maintained on follow-up.

Friendship Quality, Friendship Quantity, and Social Participation in Adults with Traumatic Brain Injury

Adults with traumatic brain injury (TBI) often report reduced social participation and loss of friends, but little is known about quality of friendship after TBI. Our objective was to characterize social participation, friendship quantity, and friendship quality of adults with TBI and a comparison group of uninjured adults. Participants included 18 adults with moderate to severe TBI and 16 of their informant friends; and 18 uninjured adults and 11 of their informant friends. The main measures used were the Participation Assessment with Recombined Tools-Objective, the Social Network Questionnaire, and the McGill Friendship Questionnaire. Participants with TBI reported significantly less social participation and had fewer total friends, although this difference was not statistically significant. Adults with TBI differed from their friends on one measure of friendship quality, but reports for friendship quality were high in both groups. Adults with TBI reported overall high levels of friendship quality despite having lower levels of social participation compared with uninjured adults. Future research should investigate how the balance of quantity and quality of friendships relates to satisfaction with social participation and overall quality of life.

Psychological Resilience Is Associated With Participation Outcomes Following Mild to Severe Traumatic Brain Injury

Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [Mage = 44.41, SDage = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD 3.02, R 0.5-13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F(13, 211) = 9.93, p < 0.05, R2 = 0.38, adjusted R2 = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.

Behavioral Clinical Trials in Moderate to Severe Pediatric Traumatic Brain Injury: Challenges, Potential Solutions, and Lessons Learned

: The purpose of this commentary is to outline the challenges encountered when conducting clinical trials of interventions for pediatric traumatic brain injury (TBI) and share potential solutions for surmounting these issues. This commentary grows out of our experience implementing 8 randomized clinical trials (RCTs) of family-centered interventions to reduce child behavior problems and caregiver/parent distress following pediatric brain injury. These studies, involving more than 600 participants from 8 clinical centers, support the feasibility of conducting RCTs with children who have sustained TBIs while highlighting potential challenges and threats to validity. The challenges of behavioral trials for pediatric TBI are apparent but not insurmountable. Careful consideration of the clinical trial issues outlined in this commentary can inform design choices and analyses when planning a clinical trial. It is critically important that investigators share their failures as well their successes to move the field of pediatric TBI intervention research forward.