Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

The contribution of executive functions to the process of return to work after brain injury: A systematic review

Acquired brain injury (ABI) is a worldwide public health issue for its high prevalence rate and the disability it produces. The consequences of ABI, including cognitive deficits, may impact return to work. This review focuses on the association between executive functions (EFs) and return to work after ABI. A systematic review of the literature between 1998 and 2023 was conducted following PRISMA guidelines. The articles were retrieved from the Pubmed, Medline and Web of Science databases. A total of 49 studies were finally selected. Impairments of EF were consistently shown to have a negative impact on return to work after an ABI. There is evidence that specific executive functions and neurobehavioral variables may affect return to work Studies showed a significant theoretical and methodological heterogeneity, representing an important limitation to understand the relation between EFs and work. There is a robust association between EFs and return to work after brain injury. Findings in this systematic review raise the need for further research on the role of specific EF profiles in the process of returning to work after brain damage.

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury

The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.

Long-Term Vocational Outcome at 15 Years from Severe Traumatic and Non-Traumatic Brain Injury in Pediatric Age

BACKGROUND

Recent studies suggest that acquired brain injury with impaired consciousness in infancy is related to more severe and persistent effects and may have a cumulative effect on ongoing development. In this work, we aim to describe vocational outcome in a group of patients at 15 years from a severe brain lesion they suffered in developmental age.

METHODS

This study included a total of 147 patients aged 1.5 to 14 years with acquired brain lesion. Clinical and functional details ("Glasgow Outcome Scale", "Functional Independent Measure" and Intelligence Quotient) were collected at the time of their first hospitalization and vocational outcome was determined after 15 years.

RESULTS

94 patients (63.9%) presented with traumatic brain injury, while 53 patients (36.1%) presented with a brain lesion of other origin. Traumatic patients had a higher probability of being partly or fully productive than non-traumatic ones: 75.5% of traumatic subjects were working-taking into account limitations due to the traumatic event-versus 62.3% of non-traumatic ones. A relationship between some clinical variables and the vocational outcome was found.

CONCLUSIONS

Rehabilitation should adequately emphasize "vocational rehabilitation" because a significant proportion of people experiencing a disorder of consciousness in childhood may show good social integration in adult age.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

Biomechanics of Traumatic Head and Neck Injuries on Women: A State-of-the-Art Review and Future Directions

The biomechanics of traumatic injuries of the human body as a consequence of road crashes, falling, contact sports, and military environments have been studied for decades. In particular, traumatic brain injury (TBI), the so-called "silent epidemic", is the traumatic insult responsible for the greatest percentage of death and disability, justifying the relevance of this research topic. Despite its great importance, only recently have research groups started to seriously consider the sex differences regarding the morphology and physiology of women, which differs from men and may result in a specific outcome for a given traumatic event. This work aims to provide a summary of the contributions given in this field so far, from clinical reports to numerical models, covering not only the direct injuries from inertial loading scenarios but also the role sex plays in the conditions that precede an accident, and post-traumatic events, with an emphasis on neuroendocrine dysfunctions and chronic traumatic encephalopathy. A review on finite element head models and finite element neck models for the study of specific traumatic events is also performed, discussing whether sex was a factor in validating them. Based on the information collected, improvement perspectives and future directions are discussed.

Assessments of Functional Cognition Used with Patients following Traumatic Brain Injury in Acute Care: A Survey of Australian Occupational Therapists

This study aimed to describe how occupational therapists working in acute care settings in Australia assess cognitive function in patients with TBI, the influences on assessment choice, and clinician perceptions of performance-based assessment. An online survey was completed by 81 occupational therapists. The most common method of cognitive assessment was reported as non-standardized observation of functional tasks (94.7%), followed by carer-report / self-report (93%). Despite their being positive perceptions of performance-based assessment there was limited use in practice. Assessment use was impacted by practical and organizational constraints including access to assessment resources, time and the built environment in acute care.

Predicting Clinical Outcomes 7-10 Years after Severe Traumatic Brain Injury: Exploring the Prognostic Utility of the IMPACT Lab Model and Cerebrospinal Fluid UCH-L1 and MAP-2

BACKGROUND

Severe traumatic brain injury (TBI) is a major contributor to disability and mortality in the industrialized world. Outcomes of severe TBI are profoundly heterogeneous, complicating outcome prognostication. Several prognostic models have been validated for acute prediction of 6-month global outcomes following TBI (e.g., morbidity/mortality). In this preliminary observational prognostic study, we assess the utility of the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) Lab model in predicting longer term global and cognitive outcomes (7-10 years post injury) and the extent to which cerebrospinal fluid (CSF) biomarkers enhance outcome prediction.

METHODS

Very long-term global outcome was assessed in a total of 59 participants (41 of whom did not survive their injuries) using the Glasgow Outcome Scale-Extended and Disability Rating Scale. More detailed outcome information regarding cognitive functioning in daily life was collected from 18 participants surviving to 7-10 years post injury using the Cognitive Subscale of the Functional Independence Measure. A subset (n = 10) of these participants also completed performance-based cognitive testing (Digit Span Test) by telephone. The IMPACT lab model was applied to determine its prognostic value in relation to very long-term outcomes as well as the additive effects of acute CSF ubiquitin C-terminal hydrolase-L1 (UCH-L1) and microtubule associated protein 2 (MAP-2) concentrations.

RESULTS

The IMPACT lab model discriminated favorable versus unfavorable 7- to 10-year outcome with an area under the receiver operating characteristic curve of 0.80. Higher IMPACT lab model risk scores predicted greater extent of very long-term morbidity (β = 0.488 p = 0.000) as well as reduced cognitive independence (β =  - 0.515, p = 0.034). Acute elevations in UCH-L1 levels were also predictive of lesser independence in cognitive activities in daily life at very long-term follow-up (β = 0.286, p = 0.048). Addition of two CSF biomarkers significantly improved prediction of very long-term neuropsychological performance among survivors, with the overall model (including IMPACT lab score, UCH-L1, and MAP-2) explaining 89.6% of variance in cognitive performance 7-10 years post injury (p = 0.008). Higher acute UCH-L1 concentrations were predictive of poorer cognitive performance (β =  - 0.496, p = 0.029), whereas higher acute MAP-2 concentrations demonstrated a strong cognitive protective effect (β = 0.679, p = 0.010).

CONCLUSIONS

Although preliminary, results suggest that existing prognostic models, including models with incorporation of CSF markers, may be applied to predict outcome of severe TBI years after injury. Continued research is needed examining early predictors of longer-term outcomes following TBI to identify potential targets for clinical trials that could impact long-ranging functional and cognitive outcomes.

Systematic Review of Sex and Gender Effects in Traumatic Brain Injury: Equity in Clinical and Functional Outcomes

Background: Although traumatic brain injury (TBI) is a leading cause of death and disability in male and female patients worldwide, little is known about the effect of sex and gender on TBI outcomes.

Objectives: This systematic review summarizes the evidence on the effect of sex and gender on core TBI outcomes.

Methods: All English-language studies from six literature databases that addressed core outcomes in adults with TBI and included sex or gender, TBI severity, and age in their analyses were considered eligible. Two reviewers extracted data, and two reviewers assessed study quality using tools recommended by the National Institutes of Health. The results were sorted according to time post-injury, injury severity, gender equity ranking of the study's country of origin, and outcomes studied. The results from the included studies were grouped based on the approach taken in reporting their respective findings.

Results and Limitations: Of 172 articles assessed, 58 studies were selected, comprising 1, 265, 955 participants with TBI (67% male across all studies) of all injury severities. All studies were conducted in countries with a very high or high human development index, while the Gender Inequality Index (GII) varied. While the heterogeneity across studies limited any meaningful conclusions with respect to the role of sex and gender, we did observe that as gender equality ranking improved, differences between male and female participants in outcomes would diminish. Inclusion of social equity parameters in the studies was limited.

Conclusions and Implications: The non-uniform findings observed bring forth the need to develop and use a comprehensive and consistent methodology in the study of sex and gender post-TBI, incorporating social equity parameters to uncover the potential social underpinnings of gender effects on health and functional outcomes.

Systematic Review Registration: CRD42018098697.

The role of occupational participation for people with traumatic brain injury: a systematic review of the literature

PURPOSE

Improving participation and quality of life is a desirable goal following traumatic brain injury (TBI). The purpose of this systematic review was to summarize existing findings concerning the role of occupational participation for persons with TBI.

METHODS

A systematic literature search using four electronic databases was followed by a review of all titles and abstracts. Articles were included if the studies were conducted with adults with TBI, used a qualitative methodology and explored the role or meaning of occupations and occupational participation from the perspectives of individuals with TBI. Following data extraction, a thematic synthesis was conducted.

RESULTS

A total of 642 articles were identified, of which 14 met all inclusion criteria. Three themes related to the role of occupations for people with TBI emerged: reflecting on change in occupational performance and occupational participation, occupational adaptation, and individual meaning of occupational participation.

CONCLUSION

The findings demonstrate the significance of occupational participation for people following TBI. Occupational participation enabled better understanding of one's abilities and limitations, assisted in occupational adaptation, and held unique meaning for participants. The findings also highlight the importance of providing long-term services focused on enabling participation in occupations in order to ensure successful adaptation following TBI.Implications for rehabilitationFor persons with TBI, occupational participation enables recognition of changes in their performance, contributes to the process of adaptation and identity (re)construction, fulfils various intrinsic needs and provides a sense of personal meaning.Rehabilitation professionals should recognize persons with TBI as occupational beings and work with individuals to identify the meaning of important occupations in the process of understanding and adapting to changes in capability, performance and participation.The rehabilitation process should focus on enabling persons to perform and participate in the occupations they want, need or are expected to do in their daily lives.National and regional health care systems should ensure that persons with TBI are provided with appropriate physical, social and institutional support and services in order to achieve meaningful occupational engagement.

A Scoping Review of Predictors of Community Integration Following Traumatic Brain Injury: A Search for Meaningful Associations

OBJECTIVE

The purpose of this scoping review was to identify predictors of community integration for adults with traumatic brain injury.

DATA SOURCES

We searched the PubMed and PsycINFO databases and reviewed references of included studies. We selected studies exploring multiple components of community integration, including instrumental activities of daily living, leisure activities, and social activities. A total of 53 studies were included.

DATA EXTRACTION

We extracted data on sample size and sample characteristics (stage of injury and recovery, severity) and examined predictor variables, outcome measures for community integration, and significant findings, reported as correlations.

DATA SYNTHESIS

We found that the predictors of community integration fell into 4 categories: demographics, injury characteristics, disability and impairments, and environmental factors. There was large variability in reported relationships for demographics (r = 0.01-0.43), injury characteristics (r = 0.01-0.58), disability/functional impairments (r = 0.003-0.98) and environmental factors (r = 0.11-0.58). Cognition, disability, mobility/physical functioning, mood, social support, and length of posttraumatic amnesia had the strongest relationships with community integration outcomes.

CONCLUSIONS

Strategies for the management of cognitive, physical, and emotional functioning, and building and training a strong support system, may facilitate community integration outcomes. Additional work is warranted to further explore the discrepancies found among studies.

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury

OBJECTIVE

To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation.

DESIGN

Retrospective cohort.

SETTING

Six TBI Model Systems (TBIMS) centers.

PARTICIPANTS

In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity.

RESULTS

At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders.

CONCLUSIONS

People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

Early cognitive impairment is common after intracranial hemorrhage with mild traumatic brain injury

BACKDROP

The incidence of early cognitive impairment (ECI) after traumatic brain injury (TBI) is unknown. We hypothesized ECI is common and can be predicted based on Glasgow Coma Scale (GCS) and Brain Injury Guideline (BIG) category.

METHODS

A single-center, retrospective review of adult trauma patients (2014-2016) with intracranial hemorrhage (ICH) and mild TBI (GCS score, 13-15) was performed. The primary outcome was ECI, defined as a Rancho Los Amigos score less than 8. Routine cognitive evaluation is performed on all ICH patients at our institution. Comparisons between ECI and no-ECI groups regarding demographic, cognitive, and clinical outcomes were evaluated using bivariate statistics. The odds of ECI were evaluated using a multivariable logistic regression.

RESULTS

There were 465 patients with mild TBI, 70.3% were male, and the average age was 53 ± 23 years. The most common mechanism of injury was fall (41.1%) followed by motor vehicle collision (15.9%). The incidence of ECI was 51.4% (n = 239). The incidence in patients with a GCS score of 15 was 42.9%, and BIG 1 category was 42.7%. There were no differences in demographics (age, sex, comorbidities), mechanism of injury, or imaging when comparing ECI patients with no-ECI patients. The GCS score was lower in the ECI group (14.4 vs. 14.7, p < 0.001). Patients with ECI were also less likely to be discharged home (58.2% vs. 78.3%, p < 0.001). Lower GCS-verbal, BIG category 3, and presence of pelvic/extremity fractures were strong risk factors for ECI in a logistic regression model adjusted for age, loss of consciousness, anticoagulants, narcotic administration, and Rotterdam score.

CONCLUSION

Half of all patients with ICH and mild TBI had ECI. Both lower initial GCS score and BIG category 3 were associated with increased likelihood of ECI. Therefore, we recommend all patients with ICH and mild TBI undergo cognitive evaluation.

LEVEL OF EVIDENCE

Prognostic Study, Level III.

Relationship Between Hispanic Nativity, Residential Environment, and Productive Activity Among Individuals With Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVE

To examine the influence of nativity and residential characteristics on productive activity among Hispanics at 1 year after traumatic brain injury (TBI).

SETTING

Acute rehabilitation facilities and community follow-up.

PARTICIPANTS

A total of 706 Hispanic individuals in the TBI Model Systems National Database.

DESIGN

Secondary data analysis from a multicenter longitudinal cohort study.

MAIN MEASURES

Nativity (foreign born or US native), productive activity derived from interview questions regarding employment status, and other demographic information. Census data were extracted by zip code to represent residential characteristics of aggregate household income and proportion of foreign language speakers (FLS).

RESULTS

Among foreign-born individuals with TBI, those living in an area with a higher proportion of FLS were 2.8 times more likely to be productive than those living in areas with a lower proportion of FLS. Among individuals living in an area with a lower proportion of FLS, US-born Hispanics were 2.7 times more likely to be productive compared with Hispanic immigrants.

CONCLUSION

The relationship between nativity and productive activity at 1 year post-TBI was moderated by the residential proportion of FLS. Findings underscore the importance of considering environmental factors when designing vocational rehabilitation interventions for Hispanics after TBI.

The Voicemail Elicitation Task: Functional Workplace Language Assessment for Persons With Traumatic Brain Injury

Purpose Politeness markers (PMs) are words that enhance cooperativity in dialogue and are an essential component of professional/work communication. Persons with moderate/severe traumatic brain injury (TBI) underuse PMs in connected speech and have employment stability issues. The voicemail elicitation task (VET) is a standardized computerized language sampling procedure measuring PM rate in role-play tasks. Our purpose is to provide preliminary data establishing the potential of a screening assessment tool for professional/work communication. Method We measured VET performance using spoken PMs per minute (PMpM). We present data from 63 persons. Forty-three participants with TBI (22-65 years old, ≥ 1-year postinjury) worked in midlevel jobs before their injury and attempted work return after injury at the same job level. Twenty participants with TBI did not maintain work > 1 year (unstably employed), and 23 did maintain work for ≥ 1 year (stably employed). Twenty controls without history of neurological impairment working at the same job level also completed the VET protocol. We analyzed the data using between-group comparison with 1-way analysis of variance and post hoc analysis. We used receiver operating characteristic curve analysis to calculate sensitivity and specificity, as well as an optimal cutoff value for a screening measure. Results Group differences, F(2, 60) = 19.59, p = .0001, η2 = .376, were identified between unstably employed persons with TBI performing with lower PMpM scores than the stably employed TBI group and the control group. Receiver operating characteristic curve analysis indicated a cutoff score of 11.55 PMpM. There was acceptable specificity (0.700, 95% CI [0.499, 0.901]) and sensitivity (0.696, 95% CI [0.508, 0.883]) for a screening tool indicating further assessment of social communication. Conclusion The VET holds promise as a clinical screening tool to identify persons at risk for social communication-related job instability after TBI and the need for a more comprehensive social communication assessment.

Characterizing Early and Late Return to Work after Traumatic Brain Injury

Facilitating successful return to work (RTW) is a key rehabilitation objective following traumatic brain injury (TBI). This study modelled early (within 6 months) and late (7-34 months) RTW by leveraging a large and comprehensive compensation database. The sample comprised 666 participants with TBI, the majority of whom sustained a moderate or severe injury caused by a motor vehicle accident. Early RTW was more likely for individuals who were pre-morbidly employed in a managerial or professional occupation (odds ratio [OR] = 2.1, confidence interval [CI] = 1.29-3.37), and those who experienced shorter post-traumatic amnesia (PTA) (OR = 0.96, CI = 0.94-0.98). RTW was less likely in the late phase for individuals who were older (hazard ratio [HR] = 0.99, CI = 0.98-1.00), experienced longer PTA (HR = 0.98, CI = 0.97-0.99), had an abdominal injury (HR = 0.90, CI = 0.67-1.21) and used more specialist practitioner (HR = 0.99, standard error [SE] = 0.98-1.00) and analgesic services (HR = 0.91, CI = 0.82-1.00). Conversely, RTW in the late phase was more likely for individuals using a greater number of specialist RTW supports (HR = 1.03, CI = 1.01-1.05). Patterns of early service utilization may therefore contribute to prediction of RTW outcome. It is encouraging that RTW was more likely for individuals using vocational supports.

The incremental value of neuropsychological assessment: A critical review

Objective: The purpose of this critical review was to evaluate the current state of research regarding the incremental value of neuropsychological assessment in clinical practice, above and beyond what can be accounted for on the basis of demographic, medical, and other diagnostic variables. The focus was on neurological and other medical conditions across the lifespan where there is known risk for presence or future development of cognitive impairment.Method: Eligible investigations were group studies that had been published after 01/01/2000 in English in peer-reviewed journals and that had used standardized neuropsychological measures and reported on objective outcome criterion variables. They were identified through PubMed and PsychInfo electronic databases on the basis of predefined specific selection criteria. Reference lists of identified articles were also reviewed to identify potential additional sources. The Grades of Recommendation, Assessment, Development and Evaluation Working Group's (GRADE) criteria were used to evaluate quality of studies.Results: Fifty-six studies met the final selection criteria, including 2 randomized-controlled trials, 9 prospective cohort studies, 12 retrospective cohort studies, 21 inception cohort studies, 2 case control studies, and 10 case series studies. The preponderance of the evidence was strongly supportive with regard to the incremental value of neuropsychological assessment in the care of persons with mild cognitive impairment/dementia and traumatic brain injury. Evidence was moderately supportive with regard to stroke, epilepsy, multiple sclerosis, and attention-deficit/hyperactivity disorder. Participation in neuropsychological evaluations was also associated with cost savings.Conclusions: Neuropsychological assessment can improve both diagnostic classification and prediction of long-term daily-life outcomes in patients across the lifespan. Future high-quality prospective cohort studies and randomized-controlled trials are necessary to demonstrate more definitively the incremental value of neuropsychological assessment in the management of patients with various neurological and other medical conditions.

Cognitive Reserve Protects Against Memory Decrements Associated With Neuropathology in Traumatic Brain Injury

OBJECTIVE

To evaluate whether cognitive reserve (CR) moderates the relationship between neuropathology and cognitive outcomes after traumatic brain injury (TBI).

SETTING

Outpatient research organization.

PARTICIPANTS

Patients with complicated mild (n = 8), moderate (n = 9), and severe (n = 44) TBI.

DESIGN

Prospective, cross-sectional study.

MAIN MEASURES

Cognitive reserve was estimated using a test of word reading (Wechsler Test of Adult Reading). Diffusion tensor imaging (functional anisotropy) was used to quantify neuropathology. Neuropsychological test scores were submitted to principal components analyses to create cognitive composites for memory, attention, executive function, and processing speed domains.

RESULTS

At lower levels of neuropathology, people with higher CR exhibited better memory than those with lower CR. This benefit diminished as neuropathology increased and disappeared at the highest levels of neuropathology. Cognitive reserve ceased exerting a protective effect at premorbid intelligence levels below average.

CONCLUSION

Cognitive reserve may differentially protect some cognitive domains against neuropathology relative to others. A clinical cutoff below which CR is no longer protective, together with a possible neuropathology ceiling effect, may be instructive for prognostication and clinical decision-making in cognitive rehabilitation.

Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age

Physical activity and exercise are important adjuncts to medical treatment for overall health in individuals with traumatic brain injury (TBI); however, many individuals do not partake in the recommended weekly exercise. The objective of this study was to investigate the barriers to exercise after TBI and determine whether these barriers varied by age. The sample was 172 adults with moderate to severe TBI who completed Barriers to Physical Exercise and Disability (B-PED) survey. Lack of interest, motivation, and energy as well as cost, lack of counseling on exercise by a physician, not having home equipment, and being too lazy were reported as barriers to exercise by all age groups. Those aged 35 to 54-years-old were more likely to report that cost, lack of transportation, having health concerns, not knowing where to exercise, and fear of leaving the home as barriers to exercise than those aged 18 to 34-years-old or 55-years-old and older. Overall, adults with TBI report multiple barriers to exercise, and these barriers vary by age.

Relating Activity and Participation Levels to Glycemic Control, Emergency Department Use, and Hospitalizations in Individuals With Type 2 Diabetes

IN BRIEF Participation in domestic, leisure, work, and community-based activities may relate to glycemic control, emergency department use, and hospitalizations in individuals with type 2 diabetes and low socioeconomic status. This study sought to determine how such role-related activity levels relate to A1C, emergency department use, and hospitalizations.

Endogenous Sex Steroids Dampen Neuroinflammation and Improve Outcome of Traumatic Brain Injury in Mice

The role of biological sex in short-term and long-term outcome after traumatic brain injury (TBI) remains controversial. The observation that exogenous female sex steroids (progesterone and estrogen) reduce brain injury coupled with a small number of clinical studies showing smaller injury in women suggest that sex steroids may play a role in outcome from TBI. We used the controlled cortical impact (CCI) model of TBI in mice to test the hypothesis that after CCI, female mice would demonstrate less injury than male mice, related to the protective role of endogenous steroids. Indeed, adult females exhibit histological protection (3.7 ± 0.5 mm³) compared to adult male mice (6.8 ± 0.6 mm³), and females that lacked sex steroids (ovex) showed increased injury compared to intact females. Consistent with histology, sensorimotor deficits measured as reduced contralateral limb use were most pronounced in male mice (31.9 ± 6.9% reduced limb use) compared to a 12.7 ± 3.8% reduction in female mice. Ovex mice exhibited behavioral deficits similar to males (31.5 ± 3.9% reduced limb use). Ovex females demonstrated increased microglial activation relative to intact females in both the peri-injury cortex and the reticular thalamic nucleus. Ovex females also demonstrated increased astrogliosis in comparison to both females and males in the peri-injury cortex. These data indicate that female sex steroids reduce brain sensitivity to TBI and that reduced acute neuroinflammation may contribute to the relative protection observed in females.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Prediction of occupational disability from psychological and neuropsychological evidence in forensic context

Within the fields of psychiatry, psychology, and neuropsychology, medical examiners are often tasked with providing an opinion about an injured individual's health prognosis and likelihood of returning to work. Traditionally, examiners have conducted such assessments by employing clinical intuition, expert knowledge, and judgment. More recently, however, an accumulation of research on factors predictive of disability has allowed examiners to provide prognostications using specific empirically supported evidence. This paper integrates current evidence for four common clinical issues encountered in forensic assessments-musculoskeletal pain, depression, Posttraumatic Stress Disorder, and traumatic brain injury. It discusses an evidence-informed, cross-diagnostic and multifactorial model of predicting disability that is emerging from the literature synthesis, along with recommendations for best forensic assessment practice.

Implementation of resource facilitation to assess referral needs and promote access to state vocational rehabilitation services in people with traumatic brain injury

Resource facilitation (RF) has shown promise for improving return to work (RTW) after traumatic brain injury (TBI), but little is known about the RF needs of people recruited from acute trauma settings. In this descriptive study, we sought to track referral needs, describe problems in accessing state vocational rehabilitation (VR) services, and highlight the role of RF in overcoming these difficulties in 45 adults with complicated mild to severe TBI seeking RTW who were recruited from acute trauma care. Participants received a referral to the state VR agency, along with RF services for up to one year. Case coordinators (CCs) conducted biweekly assessments, provided referrals, and helped address problems in accessing services. On average 4.92 referrals were generated per participant; 91% required referrals. CCs made 44% of referrals, while physicians/other healthcare professionals generated 33% and VR counsellors generated 23%. CCs filled a gap in referring for financial and transportation difficulties. Two case studies illustrate implementation of the RF paradigm. RF provides systematic assessment and referral for services needed to facilitate utilisation of state VR services. Among persons with TBI recruited from acute trauma settings in the US, CCs provide referrals that are often not generated by other sources.

Return to Work and Social Communication Ability Following Severe Traumatic Brain Injury

PURPOSE

Return to competitive employment presents a major challenge to adults who survive traumatic brain injury (TBI). This study was undertaken to better understand factors that shape employment outcome by comparing the communication profiles and self-awareness of communication deficits of adults who return to and maintain employment with those who do not.

METHOD

Forty-six dyads (46 adults with TBI, 46 relatives) were recruited into 2 groups based on the current employment status (employed or unemployed) of participants with TBI. Groups did not differ in regard to sex, age, education, preinjury employment, injury severity, or time postinjury. The La Trobe Communication Questionnaire (Douglas, O'Flaherty, & Snow, 2000) was used to measure communication. Group comparisons on La Trobe Communication Questionnaire scores were analyzed by using mixed 2 × 2 analysis of variance (between factor: employment status; within factor: source of perception).

RESULTS

Analysis yielded a significant group main effect (p = .002) and a significant interaction (p = .004). The employed group reported less frequent difficulties (self and relatives). Consistent with the interaction, unemployed participants perceived themselves to have less frequent difficulties than their relatives perceived, whereas employed participants reported more frequent difficulties than their relatives.

CONCLUSION

Communication outcome and awareness of communication deficits play an important role in reintegration to the workplace following TBI.

Vocational outcome 6-15 years after a traumatic brain injury

PRIMARY OBJECTIVE

To describe vocational outcome 6-15 years after a traumatic brain injury (TBI) among individuals who were productive by working or studying at the time of their TBI and determine the associations with variables related to the time of injury and at follow-up.

METHODS AND PROCEDURES

Thirty-four individuals with a mild TBI and 45 with a moderate-to-severe TBI were assessed on average 10 years post-injury. Logistic regression was used to determine the association between their current vocational situation and variables related to the time of injury (gender, age, injury severity and educational level) and at follow-up (time since injury, marital status and overall disability).

RESULTS

A total of 67% were productive at follow-up. Age at injury, injury severity and the degree of disability at follow-up were strongly associated with being productive. Younger individuals with milder TBI and less severe disability were significantly more likely to be fully productive. No significant associations were found between productivity and gender, education, time since injury or marital status.

CONCLUSIONS

This study indicates that return to productivity in a long-term perspective after a TBI is possible, in particular when the individual is young, has sustained a mild TBI and has a milder form of overall disability.

Changes in activity participation following traumatic brain injury

Traumatic brain injury (TBI) often results in impairments in cognitive skills as well as depression. As a result of these changes in cognition and mood, individuals with TBI may reduce their levels of participation and often report reduced health-related quality of life (HrQOL). The current study compares levels of past and present activity participation between healthy participants and persons with TBI using a client-centred approach in measurement. We additionally examine the relationship between activity participation, emotional functioning and HrQOL in persons with TBI. Fifty-two individuals with TBI who live in the community and 30 healthy age-matched controls performed a battery of cognitive tests and rated their affective symptomatology and activity participation (using the Activity Card Sort Test). Participants with TBI reported significantly lower current activity participation compared to controls. Current levels of activity and participation in the TBI sample were significantly related to age, time since injury, and HrQOL. Additionally, depressive symptomatology was significantly associated with HrQOL, but not with activity participation. Following TBI, levels of activity participation are reduced in most aspects of life, but more profoundly in social activities, high demand leisure activities and household activities. Additionally, high levels of depressive symptoms are associated with negative reports of HrQOL, regardless of current levels of activity participation.

Stability of employment over the first 3 years following traumatic brain injury

OBJECTIVE

To examine the stability of employment between 1 and 3 years following traumatic brain injury (TBI) and to identify the variables associated with continued employment throughout this time span.

PARTICIPANTS

This study included 236 individuals with predominantly moderate to very severe TBI, who had received rehabilitation in the context of a no-fault accident compensation system. Participants were eligible for the current study if they were employed before injury and reported their employment status at 1, 2, and 3 years following their injury as part of a longitudinal head injury outcome study.

RESULTS

Only 44% of participants remained employed at each of the 3 years following TBI. There was also substantial transition into and out of employment across the 3 years. Significantly greater instability in employment was reported by individuals who were machinery operators or laborers before injury, had a longer duration of posttraumatic amnesia, reported more cognitive difficulties, and were less mobile 1 year following their injury.

CONCLUSION

A number of important factors determine the likelihood of achieving stability in employment following TBI. Findings from the current study support the continued need to identify ways in which physical as well as cognitive changes contribute to employment following TBI. Further examination is needed to identify possible compensatory strategies or job modifications to maximize the likelihood of job retention.

Long-term outcomes after moderate-to-severe traumatic brain injury among military veterans: Successes and challenges

OBJECTIVE

To assess long-term outcomes after traumatic brain injury (TBI) among veterans and service members.

SETTING

Regional Veterans Affairs medical centre.

PARTICIPANTS

One hundred and eighteen veterans and military personnel, aged 23-70 years (median = 35 years), 90% male, had moderate-to-severe TBI (82% in coma > 1 day, 85% amnesic > 7 days), followed by acute interdisciplinary rehabilitation 5-16 years ago (median = 8 years).

DESIGN

Cross-sectional analysis of live interviews conducted via telephone.

MAIN MEASURES

TBI follow-up interview (occupational, social, cognitive, neurologic and psychiatric ratings), Community Integration Questionnaire, Disability Rating Scale (four indices of independent function) and Satisfaction with Life Scale.

RESULTS

At follow-up, 52% of participants were working or attending school; 34% ended or began marriages after TBI, but the overall proportion married changed little. Finally, 22% were still moderately-to-severely disabled. However, 62% of participants judged themselves to be as satisfied or more satisfied with life than before injury. Injury severity, especially post-traumatic amnesia, was correlated with poorer outcomes in all functional domains.

CONCLUSIONS

After moderate-severe TBI, most veterans assume productive roles and are satisfied with life. However, widespread difficulties and functional limitations persist. These findings suggest that veteran and military healthcare systems should continue periodic, comprehensive follow-up evaluations long after moderate-to-severe TBI.

Interdisciplinary residential treatment of posttraumatic stress disorder and traumatic brain injury: effects on symptom severity and occupational performance and satisfaction

OBJECTIVE. This study examined outcomes of an 8-wk residential treatment program for veterans with posttraumatic stress disorder (PTSD) and a history of traumatic brain injury (TBI). METHOD. Twenty-six veterans completed the Canadian Occupational Performance Measure, Clinician-Administered PTSD Scale, Beck Depression Inventory-2nd Edition, and PTSD Checklist before and after treatment. RESULTS. Veterans demonstrated significant improvements in occupational performance and satisfaction with their performance, as well as in PTSD and depression symptom severity after residential PTSD/TBI treatment. Additionally, improvements in occupational performance and satisfaction were associated with decreases in depression symptom severity. CONCLUSION. Although preliminary, results suggest that veterans with PTSD and a history of TBI experienced significant decreases in PTSD and depression symptom severity and improvement in self-perception of performance and satisfaction in problematic occupational areas. Changes in occupational areas and depression symptom severity were related, highlighting the importance of interdisciplinary treatment.

Validity of the Functional Loewenstein Occupational Therapy Cognitive Assessment (FLOTCA)

The Functional Loewenstein Occupational Therapy Cognitive Assessment (FLOTCA) was developed to assess integrative higher cognitive abilities in people with traumatic brain injury (TBI). The FLOTCA measures performance on three tasks: navigating on a map, organizing a toolbox, and planning a daily schedule. This study assessed the psychometric properties of the FLOTCA with a sample of 25 participants with TBI ages 18–49 and 25 matched healthy participants. The FLOTCA showed high interrater reliability (intraclass correlation = .996) and internal consistency reliability for the total score (α = .82). Construct validity was supported for the total score, t (48) = −5.48, d = 1.52, and the separate tasks. Moderate ecological validity was obtained with the combined FIM™ and Functional Assessment Measure, r (19) = .44, p &lt; .05. The results indicate that the FLOTCA can be used to assess higher cognitive abilities in functioning and can serve as the basis for intervention planning.

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom

This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT "Lab" model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.

Effects of concomitant spinal cord injury and brain injury on medical and functional outcomes and community participation

BACKGROUND

There are limited data on the interactions between concomitant spinal cord injury (SCI) and traumatic brain injury (TBI) in terms of medical, psychological, functional, and community outcomes.

OBJECTIVE

To investigate the hypothesis that in addition to SCI-associated sensory-motor impairments, people with dual diagnosis would experience additional TBI-associated cognitive impairments that would have a negative impact on community reintegration.

METHODS

Cross-sectional, case-matched study comparing a consecutive sample of participants with dual diagnosis (n = 30) to an SCI group (n = 30) and TBI group (n = 30). Participants who were on average 3.6 years postrehabilitation discharge were interviewed using a battery of standardized outcome measures.

RESULTS

Length of rehabilitation stay was significantly longer in SCI and dual diagnosis participants. Fatigue, pain, sexual dysfunction, depression, and sleep disturbances were frequently reported by all groups. Similar levels of anxiety and depression were reported by participants in all groups, however TBI participants reported higher stress levels. All groups achieved mean FIM scores > 100. The dual diagnosis and SCI groups received more daily care and support than TBI participants. Similar levels of community reintegration were achieved by all groups with a high level of productive engagement in work, study, or volunteer activities.

CONCLUSIONS

The findings of this study do not support the hypotheses. Postrehabilitation functioning was better than anticipated in adults with dual diagnosis. The contribution of rehabilitation factors, such as longer admission time to develop compensatory techniques and strategies for adaptation in the community, may have contributed to these positive findings.

The effect of environmental barriers on community integration for individuals with moderate to severe traumatic brain injury

OBJECTIVE

To describe environmental barriers endorsed by individuals with traumatic brain injury during the first 6 months after discharge and determine their effect on community integration.

DESIGN

Prospective longitudinal study with data collected at predischarge and at 1, 3, and 6 months postdischarge.

PARTICIPANTS

One hundred thirty-five individuals with a diagnosis of traumatic brain injury discharged from a large metropolitan hospital to a home/community environment.

MEASURES

Sydney Psychosocial Reintegration Scale; Craig Hospital Inventory of Environmental Factors; and Mayo-Portland Adaptability Inventory-4.

RESULTS

Multiple regression analyses indicated that environmental barriers arising during the transition from hospital to home had a negative association with community integration outcomes. Physical barriers were most commonly endorsed, but attitudinal barriers were significantly correlated with relationship changes.

CONCLUSION

Environmental barriers should be addressed in rehabilitation and considered in policy development for people with traumatic brain injury. Future research on the measurement of environmental barriers is recommended.

Improved occupational performance of young adults with a physical disability after a vocational rehabilitation intervention

PURPOSE

The purpose of this study was to investigate into more detail how occupational performance of participants of a 1-year multidisciplinary vocational rehabilitation intervention changed over time, using a broad focus on three areas of occupational performance, addressing work, as well as self-care and leisure. In addition, we explored differences between employed and unemployed persons.

METHODS

In a pre-post-intervention design, changes in occupational performance, addressing work, self-care and leisure, were evaluated using the Canadian Occupational Performance Measure (COPM) and the Occupational Performance History Interview (OPHI-II).

RESULTS

Eleven young adults (median 22 years) with physical disabilities participated. Post-intervention, participants experienced fewer problems and showed improved occupational performance in work, as well as self-care and leisure, and improved satisfaction with performance. Participants also showed improved occupational identity and occupational competence, and total scores on OPHI-II. Participants who did not achieve employment did not differ in demographic characteristics. They experienced problems in all three areas of occupational performance at pre-intervention, and more difficulty in interacting in occupational settings (environment). Post-intervention, their levels of occupational identity, competence and settings were similar to those of employed persons.

CONCLUSIONS

Participants showed improved occupational performance after the intervention. The goal of employment and the broad integrated approach of the intervention seemed to motivate participants to resolve problems in work, as well as self-care and leisure. Unemployed persons faced problems in all three areas of occupational performance at start. Although they seemed to catch up during the intervention, they did not achieve employment within 1 year.

Modeling the prospective relationships of impairment, injury severity, and participation to quality of life following traumatic brain injury

Identifying reliable predictors of positive adjustment following traumatic brain injury (TBI) remains an important area of inquiry. Unfortunately, much of available research examines direct relationships between predictor variables and outcomes without attending to the contextual relationships that can exist between predictor variables. Relying on theoretical models of well-being, we examined a theoretical model of adjustment in which the capacity to engage in intentional activities would be prospectively associated with greater participation, which in turn would predict subsequent life satisfaction and perceived health assessed at a later time. Structural equation modeling of data collected from 312 individuals (226 men, 86 women) with TBI revealed that two elements of participation--mobility and occupational activities--mediated the prospective influence of functional independence and injury severity to optimal adjustment 60 months following medical discharge for TBI. The model accounted for 21% of the variance in life satisfaction and 23% of the variance in self-rated health. Results indicate that the effects of functional independence and injury severity to optimal adjustment over time may be best understood in the context of participation in meaningful, productive activities. Implications for theoretical models of well-being and for clinical interventions that promote adjustment after TBI are discussed.

Community integration outcomes after traumatic brain injury due to physical assault

BACKGROUND

Community integration is considered an ultimate goal for rehabilitation after traumatic brain injury (TBI).

PURPOSE

To determine (a) whether differences exist in rehabilitation outcomes between intentional and unintentional TBI populations and (b) whether TBI from assault is a predictor of community integration following inpatient rehabilitation.

METHOD

Retrospective cohort study using population-based data from Canadian hospital administration records, 2001 to 2006. Outcome measure was the Reintegration to Normal Living Index (RNLI).

FINDINGS

From a sample of 243 persons, 24 (9.9%) had sustained TBI from physical assault. Persons with TBI from physical assault reported significantly lower scores on two items on the RNLI's Daily Functioning subscale: "recreation" and "family role."

IMPLICATIONS

These findings suggest that targeted intervention in these specific areas could be beneficial, which are often primarily addressed by occupational therapists in both inpatient rehabilitation and community settings.

Inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury: a systematic and evidence-based approach

INTRODUCTION

This paper introduces an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. This guideline aims to explicate the processes and factors relevant to vocational evaluation to assist evaluators (i.e. health care teams, individuals and employers) in collaboratively determining if clients are able to work and to make recommendations for work entry, re-entry or vocational planning.

METHODS

Methods in the Canadian Medical Association's (CMA) Handbook on Clinical Practice Guideline and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were utilized to ensure rigour. Steps in the CMA handbook were followed and included: (1) identifying the guideline's objective and questions; (2) systematic literature review; (3) study selection and quality appraisal; (4) development of clear recommendations by key stakeholders; (5) guideline pilot testing and endorsement.

RESULTS

The resulting guideline includes 17 key recommendations within the seven domains: (1) evaluation purpose and rationale; (2) initial intake process; (3) assessment of the personal domain; (4) assessment of the environment; (5) assessment of occupational/job requirements; (6) analysis and synthesis; (7) evaluation recommendations.

CONCLUSIONS

The guideline may be useful to individually practicing clinicians, health care teams, employers and individuals with TBI. Future research will formally examine the success of the guideline's implementation.