Community Outcomes Following Traumatic Brain Injury

Mapping the costs and socioeconomic characteristics involved in traumatic brain injuries: a scoping review

OBJECTIVE

To identify the articles in the existing literature that analyse healthcare costs according to the socioeconomic position (pre- or post-injury) for traumatic brain injury survivors. Secondary aims were to describe the types of costs and socioeconomic characteristics and to determine whether socioeconomic characteristics affect the risk of traumatic brain injury or whether the consequences of trauma alter living conditions post-injury.

METHODS

This scoping review followed the methods proposed by Arksey and O'Malley. The literature search was performed in 5 databases.

RESULTS

Twenty-two articles were included, published between 1988 and 2023. Only 2 articles (9%) followed the guidelines for economic evaluation of healthcare programmes and 2 articles (9%) evaluated socioeconomic position "completely" with 3 main individual measures of socioeconomic characteristics (i.e., education, income, and occupation). The relationship between costs and socioeconomic characteristics could vary in 2 ways in traumatic brain injury: socioeconomic disadvantage was mostly associated with higher healthcare costs, and the cost of healthcare reduced the survivors' living conditions.

CONCLUSION

This work highlights the need for a detailed and methodologically sound assessment of the relationship between socioeconomic characteristics and the costs associated with trauma. Modelling the care pathways of traumatic brain injury would make it possible to identify populations at risk of poor recovery or deterioration following a TBI, and to develop specific care pathways. The aim is to build more appropriate, effective, and equitable care programmes.

"Somewhere along the line, your mask isn't going to be fitting right": institutional racism in Black narratives of traumatic brain injury rehabilitation across the practice continuum

BACKGROUND

Over two decades of research about traumatic brain injury (TBI) rehabilitation emphasized the persistence of racial health disparities in functional outcomes that disproportionately impact Black populations without naming or addressing racism as the root problem. Further, the experiences of Black people with TBI have yet to be documented and accounted for in scientific scholarship from the perspectives of Black persons in Canada.

PURPOSE

This study intended to examine the rehabilitation narratives of Black TBI survivors, family caregivers, and rehabilitation providers and use critical race theory as a conceptual framework to understand how anti-Black racism manifests in those experiences.

METHODS

Through critical narrative inquiry informed by a critical constructivist paradigm and a critical race theory lens, in-depth narrative interviewing were conducted with seven survivors, three family caregivers, and four rehabilitation providers. Data were analyzed using reflexive thematic analysis within and across groups of participants to conceptualize themes and sub-themes.

FINDINGS

Themes captured how racism becomes institutionalized in TBI rehabilitation: (1) the institutional construction of deficient Black bodies, (2) the institutional construction of rehabilitation access, (3) the institutional investment in resisting and approximating whiteness in rehabilitation practice, and (4) the institutional construction of deficient Black futures.

CONCLUSION

Study findings point to the dire need to ensure rehabilitation programs, services, and the delivery of care are not determined based on inequitable practices, racial biases and assumptions about Black people, which determine who deserves to get into rehabilitation and have opportunities to be supported in working towards living a full and meaningful life.

Mapping the institutionalization of racism in the research about race and traumatic brain injury rehabilitation: implications for Black populations

PURPOSE

Traumatic brain injury (TBI) is a chronic disease process and a public health concern that disproportionately impacts Black populations. While there is an abundance of literature on race and TBI outcomes, there is a lack of scholarship that addresses racism within rehabilitation care, and it remains untheorized. This article aims to illuminate how racism becomes institutionalized in the scientific scholarship that can potentially inform rehabilitation care for persons with TBI and what the implications are, particularly for Black populations.

MATERIAL AND METHODS

Applying Bacchi's What's the Problem Represented to be approach, the writings of critical race theory (CRT) are used to examine the research about race and TBI rehabilitation comparable to CRT in other disciplines, including education and legal scholarship.

RESULTS

A CRT examination illustrates that racism is institutionalized in the research about race and TBI rehabilitation through colourblind ideologies, meritocracy, reinforcement of a deficit perspective, and intersections of race and the property functions of whiteness. A conceptual framework for understanding institutional racism in TBI rehabilitation scholarship is presented.

CONCLUSIONS

The findings from this article speak to the future of TBI rehabilitation research for Black populations, the potential for an anti-racist agenda, and implications for research and practice.

Racial and ethnic differences in the association between mild traumatic brain injury and work duty limitations in the US military

OBJECTIVE

This study examined racial and ethnic differences in the association between mild traumatic brain injury (mTBI) and work duty limitations in active-duty service members (ADSMs).

METHODS

This study used retrospective and cross-sectional data from the 2019-2021 Military Health System Data Repository on 910,700 ADSMs who were 18-64 years old and were grouped into racial and ethnic categories of White, non-Hispanic; Black, non-Hispanic; Hispanic/Latino; and Asian or Pacific Islander, non-Hispanic.

RESULTS

Descriptive statistics showed that Black, Hispanic/Latino, and Asian or Pacific Islander patients had a lower proportion of having a diagnosis of mTBI compared to White patients (ps < 0.001). Further, the proportion of history of deployment varied by racial and ethnic group and deployment location. Multivariate logistic regression results showed odds of 1.52 (p < 0.001) for White patients with mTBI, odds of 1.61 (p < 0.001) for Black patients with mTBI, odds of 1.57 (p < 0.001) for Hispanic/Latino patients with mTBI, and odds of 1.99 (p < 0.001) for Asian or Pacific Islander patients with mTBI for being placed on work duty limitations.

DISCUSSION

These results advance our understanding of the work duty limitations for racial/ethnic minority patients with mTBI in the Military Health System.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

Comparison of Informational and Educational Resource Provision for Individuals Living With Traumatic Brain Injury Based on Language, Nativity, and Neighborhood

OBJECTIVE

To examine a resource provision program for individuals living with moderate-to-severe traumatic brain injury (TBI), using a comparison of the resources provided across social differences of language, nativity, and neighborhood.

SETTING

The Rusk Rehabilitation TBI Model System (RRTBIMS) collects data longitudinally on individuals from their associated private and public hospitals, located in New York City.

PARTICIPANTS

A total of 143 individuals with TBI or their family members.

DESIGN

An observational study of relative frequency of resource provision across variables of language, nativity, and neighborhood, using related-samples nonparametric analyses via Cochran's Q test.

MAIN MEASURES

Variables examined were language, place of birth, residence classification as medically underserved area/population (MUA), and resource categories.

RESULTS

Results indicate that US-born persons with TBI and those living in medically underserved communities are provided more resources than those who are born outside the United States or reside in communities identified as adequately medically served. Language was not found to be a factor.

CONCLUSION

Lessons learned from this research support the development of this resource provision program, as well as guide future programs addressing the gaps in health information resources for groups negatively impacted by social determinants of health (SDoH). An approach with immigrant participants should take steps to elicit questions and requests, or offer resources explicitly. We recommend research looking at what interpreter strategies are most effective and research on SDoH in relation to the dynamic interaction of variables in the neighborhood setting.

Racial/Ethnic Differences in Traumatic Brain Injury: Pathophysiology, Outcomes, and Future Directions

Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S. Results of the review showed significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites. We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.

U.S. vs. Foreign Nativity and 10-Year Trajectories of Mental Health after Traumatic Brain Injury: A Model Systems Study

BACKGROUND

Previous research has found racial and ethnic disparities in life satisfaction, depression, and anxiety after traumatic brain injury (TBI). However, limited studies have examined differences in these variables between U.S.- and foreign-born individuals with TBI. The purpose of this study was to examine whether differences exist in mental health outcomes between U.S.- and foreign-born individuals with TBI at 1, 2, 5, and 10 years after injury, as well as examine whether demographic and injury-related characteristics account for these differences.

METHOD

Participants were 8289 individuals with TBI who identified as U.S.-born and 944 who identified as born outside the U.S. in the TBI Model Systems study. Participants completed measures of mental health outcomes at 1, 2, 5, and 10 years after injury.

RESULTS

Foreign-born individuals with TBI had comparable levels of depression and anxiety trajectories to U.S.-born individuals, yet higher life satisfaction trajectories, even after controlling for demographic and injury-related variables.

CONCLUSION

Rehabilitation professionals should consider in their clinical work the mechanisms that likely influence mental health outcomes among foreign-born individuals, including family-based values that increase resilience, as well as the possible under-reporting of mental health symptoms along the lines of cultural norms.

Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury

Objective

The aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI).

Methods

Individuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio.

Results

After adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models.

Conclusion

This exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.

Assessing prospective and retrospective metacognitive accuracy following traumatic brain injury remotely across cognitive domains

The ability to monitor one's behaviour is frequently impaired following TBI, impacting on patients' rehabilitation. Inaccuracies in judgement or self-reflection of one's performance provides a useful marker of metacognition. However, metacognition is rarely measured during routine neuropsychology assessments and how it varies across cognitive domains is unclear. A cohort of participants consisting of 111 TBI patients [mean age = 45.32(14.15), female = 29] and 84 controls [mean age = 31.51(12.27), female = 43] was studied. Participants completed cognitive assessments via a bespoke digital platform on their smartphones. Included in the assessment were a prospective evaluation of memory and attention, and retrospective confidence judgements of task performance. Metacognitive accuracy was calculated from the difference between confidence judgement of task performance and actual performance. Prospective judgment of attention and memory was correlated with task performance in these domains for controls but not patients. TBI patients had lower task performance in processing speed, executive functioning and working memory compared to controls, maintaining high confidence, resulting in overestimation of cognitive performance compared to controls. Additional judgments of task performance complement neuropsychological assessments with little additional time-cost. These results have important theoretical and practical implications for evaluation of metacognitive impairment in TBI patients and neurorehabilitation.

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.

Functional motor improvement during inpatient rehabilitation among older adults with traumatic brain injury

BACKGROUND

Older adults comprise an increasingly large proportion of patients with traumatic brain injury (TBI) receiving care in inpatient rehabilitation facilities (IRF). However, high rates of comorbidities and evidence of declining preinjury health among older adults who sustain TBI raise questions about their ability to benefit from IRF care.

OBJECTIVES

To describe the proportion of older adults with TBI who exhibited minimal detectable change (MDC) and a minimally clinically important difference (MCID) in motor function from IRF admission to discharge; and to identify characteristics associated with clinically meaningful improvement in motor function and better discharge functional status.

DESIGN

This retrospective cohort study used Medicare administrative data probabilistically linked to the National Trauma Data Bank to estimate the proportion of patients whose motor function improved during inpatient rehabilitation and identify factors associated with meaningful improvement in motor function and motor function at discharge.

SETTING

Inpatient rehabilitation facilities in the United States.

PATIENTS

Fee-for-service Medicare beneficiaries with TBI.

MAIN OUTCOME MEASURES

Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) in the Functional Independence Measure motor (FIM-M) score from admission to discharge, and FIM-M score at IRF discharge.

RESULTS

From IRF admission to discharge 84% of patients achieved the MDC threshold, and 68% of patients achieved the MCID threshold for FIM-M scores. Factors associated with a higher probability of achieving the MCID for FIM-M scores included better admission motor and cognitive function, lower comorbidity burden, and a length of stay longer than 10 days but only among individuals with lower admission motor function. Older age was associated with a lower FIM-M discharge score, but not the probability of achieving the MCID in FIM-M score.

CONCLUSION

Older adults with TBI have the potential to improve their motor function with IRF care. Baseline functional status and comorbidity burden, rather than acute injury severity, should be used to guide care planning.

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.

Perceived health after adult traumatic brain injury: a Group-Based Trajectory Modeling (GBTM) analysis

OBJECTIVE

To provide nationally representative estimates of adults with traumatic brain injury (TBI) and identify clusters of individuals with TBI who follow similar perceived health trajectories using group-based trajectory modeling.

PARTICIPANTS

Adults (≥18 years old) from panels 9-19 (2004-2015) of the Medical Expenditure Panel Survey (MEPS) who experienced a TBI (n = 949).

DESIGN

Data from MEPS, a nationally representative database of noninstitutionalized individuals in the USA, were used to 1) produce a national annual estimate of adults with TBI and 2) identify subgroups of patients with TBI who followed different general and mental health trajectories.

MAIN MEASURES

Perceived general health (PGH), perceived mental health (PMH).

RESULTS

On average, 502 adults per 100,000 noninstitutionalized US adults experienced a TBI annually, and about one million adults are living with a TBI. Three distinct trajectory groups were identified in models of both perceived general health (PGH) and perceived mental health (PMH). TBI type, sex, and persistent disability predicted assignment to a group in the PGH model. TBI type, sex, age, insurance status, family poverty status, and persistent disability predicted assignment to a PMH trajectory.

CONCLUSION

Referrals and early-intervention resources should be distributed to individuals with increased risk of following low PGH and/or PMH trajectories.

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.

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults

OBJECTIVE

To determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center.

DESIGN

Retrospective cohort study.

SETTING

R Adams Cowley Shock Trauma Center.

PARTICIPANTS

Black and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902).

MAIN OUTCOME MEASURES

We assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities.

RESULTS

There were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70).

CONCLUSIONS

In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.

The impact of cultural background on outcome following traumatic brain injury

Most traumatic brain injury (TBI) outcome studies have been conducted in developed countries involving individuals from the dominant culture. The present study compared outcomes following TBI in individuals from Culturally and Linguistically Diverse (CALD) backgrounds with those from non-CALD backgrounds. 103 CALD and 103 non-CALD participants with predominantly moderate to severe TBI completed a series of questionnaires an average of 22 months post-injury. Groups were comparable in most demographic and injury-related variables, but CALD participants had lower pre-injury employment rates. Individuals in the CALD group were significantly less independent in light domestic duties, shopping, and financial management and reported significantly lower cognitive independence, mobility, and participation in occupational and social activities than non-CALD participants post-injury. They also reported heightened awareness of post-injury deficits, different beliefs regarding injury consequences and factors aiding recovery, more anxiety and depression symptoms, and less problem-focused coping. Higher functional outcome was associated with having a value system that is Australian, younger age at injury, and higher education. Overall, independent of rehabilitation access, individuals from a CALD background showed poorer functional outcome following TBI than those from a non-CALD background. Addressing this discrepancy should be a priority for rehabilitation programmes.

Effectiveness of an Educational Intervention on Reducing Misconceptions Among Ethnic Minorities With Complicated Mild to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate the effectiveness of an educational intervention designed to reduce traumatic brain injury (TBI)-related misconceptions among blacks and Latinos with complicated mild to severe TBI.

DESIGN

Randomized controlled trial with masked 1-month follow-up.

SETTING

Community.

PARTICIPANTS

Persons (N=52) with complicated mild to severe TBI (mean best day 1 Glasgow Coma Scale score, 11.27±3.89) were randomly recruited from 141 eligible participants (mean age, 37.71±13.88y; age range, 19-66y; mean months postinjury, 24.69±11.50); 25 participants (48.1%) of participants were black and 27 (51.9%) were Hispanic/Latino. Of the Hispanic/Latino participants, 18 (66.7%) were non-U.S. born and 12 (44.4%) spoke Spanish as their primary language. Twenty-seven individuals were randomized to the educational intervention group and 25 were randomized to the wait-list control group.

INTERVENTIONS

Single-session educational intervention with written materials provided in English or Spanish.

MAIN OUTCOME MEASURES

Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire administered at baseline and 1-month follow-up.

RESULTS

After controlling for ethnic and language differences, a significant between-group main effect (P=.010) and a significant time-group interaction for the Common Misconceptions about Traumatic Brain Injury Questionnaire were noted (Wilks Λ=.89; F_1,46=6.00; P=.02). The intervention group showed a decrease in TBI misconception percentages, whereas the wait-list control group maintained similar percentages. At 1-month follow-up, the wait-list control group reported more misconceptions than did the intervention group (P=.019).

CONCLUSIONS

An educational intervention developed to address the recovery process, common symptoms, and ways to handle the symptoms provides promise as a tool to decrease TBI misconceptions among persons from ethnically and educationally diverse backgrounds. The effects of therapist characteristics and the client-therapist relation on outcomes should be further explored.

Exploration of Individual and Family Factors Related to Community Reintegration in Veterans With Traumatic Brain Injury

BACKGROUND

Community reintegration (CR) poses a major problem for military veterans who have experienced a traumatic brain injury (TBI). Factors contributing to CR after TBI are poorly understood.

OBJECTIVE

To address the gap in knowledge, an ecological framework was used to explore individual and family factors related to CR.

DESIGN

Baseline data from an intervention study with 83 veterans with primarily mild to moderate TBI were analyzed. Instruments measured CR, depressive symptoms, physical health, quality of the relationship with the family member, and sociodemographics. Posttraumatic stress disorder and TBI characteristics were determined through record review.

RESULTS

Five variables that exhibited significant bivariate relationships with CR (veteran rating of quality of relationship, physical functioning, bodily pain, posttraumatic stress disorder diagnosis, and depressive symptoms) were entered into hierarchical regression analysis. In the final analysis, the five variables together accounted for 35% of the variance, but only depression was a significant predictor of CR, with more depressed veterans exhibiting lower CR.

CONCLUSIONS

Efforts to support CR of Veterans with TBI should carefully assess and target depression, a modifiable factor.

Enrollment of racially/ethnically diverse participants in traumatic brain injury trials: effect of availability of exception from informed consent

BACKGROUND

The Final Rule regulations were developed to allow exception from informed consent (EFIC) to enable clinical trial research in emergency settings where major barriers exist for informed consent. There is little known evidence of the effect of the Final Rule in minority enrollment in clinical trials, particularly in traumatic brain injury (TBI) trials. A clinical trial funded by the National Institute of Neurological Disorders and Stroke was conducted to study the effects of erythropoietin on cerebral vascular dysfunction and anemia in subjects with TBI. There were periods of time when EFIC was and was not available for enrollment into the study.

PURPOSE

To explore the effect of EFIC availability on TBI trial enrollment of minority versus non-minority subjects.

METHODS

Minority status of screened (n = 289) and enrolled (n = 191) TBI subjects was determined for this study. We tested for the presence of a minority and EFIC availability interaction in a multiple logistic regression model after controlling for EFIC and minority group main effects and other covariates.

RESULTS

An interaction between the availability of EFIC minority and non-minority enrollment was not detected (odds ratio = 1.22; 95% confidence interval (CI) = 0.29-5.16).

LIMITATIONS

Our study was conducted at a single site, and the CI for the EFIC and minority interaction term was wide. Therefore, a small interaction effect cannot be ruled out.

CONCLUSION

EFIC increased the odds of being enrolled regardless of minority status.

The Community Integration Questionnaire: factor structure across racial/ethnic groups in persons with traumatic brain injury

OBJECTIVE

To examine the factor structure and construct validity of the Community Integration Questionnaire, a widely used measure of community participation among individuals with traumatic brain injury (TBI), among 3 racial/ethnic groups.

DESIGN

Prospective longitudinal cohort study.

SETTING

Enrollment in acute inpatient TBI rehabilitation with follow-up at 1 year after injury.

PARTICIPANTS

A total of 1756 persons with TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) national Database.

MAIN OUTCOME MEASURE

Community Integration Questionnaire at 1 year after injury.

RESULTS

The goodness of fit for the factor structure of the Community Integration Questionnaire, separating items into Home Competency, Social Integration, and Productive Activity, was satisfactory for whites but not for blacks or Hispanics.

CONCLUSIONS

Clinicians and researchers should take race/ethnicity into account when utilizing measures of community integration.

Incidence of hospital-admitted severe traumatic brain injury and in-hospital fatality rates in a Pacific Island country: a 5-year retrospective study

BACKGROUND

Epidemiology of severe traumatic brain injury (TBI) is poorly defined in the Pacific region, including in New Caledonia. The aim of this study was to assess the incidence, causes and outcome of hospital-admitted severe TBI in the whole population of New Caledonia.

METHODS

A retrospective study on patients with severe TBI admitted to the only trauma centre during the 5-year period (2008-2012) was performed. The electronic patient register was searched for diagnoses of intracranial injuries to identify patients. Severe TBI was defined as a Glasgow Coma Scale Score ≤ 8 during the first 24 hours after injury.

RESULTS

The annual incidence ranged from 10/100 000 in 2010 to 15/100 000 in 2011. Road traffic accidents (n = 109; 71%), falls (n = 26; 17%) and assaults (n = 19; 12%) were causes of severe TBI. Young Melanesian adults (median age = 26 [19-36]) were the most affected. In ICU, the overall case-fatality rate was 25%. The mortality rate was the highest among victims of assaults (47%).

CONCLUSIONS

The high incidence of hospital-admitted patients with severe TBI in this study combined with high in-ICU mortality rates supports the need for targeted public health action to prevent assaults and traffic road accidents in this vulnerable population.

Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury

Post-acute inpatient rehabilitation services are associated with improved functional outcomes among persons with traumatic brain injury (TBI). We sought to investigate racial and insurance-based disparities in access to rehabilitation. Data from the Nationwide Inpatient Sample from 2005-2010 were analyzed using standard descriptive methods and multivariable logistic regression to assess race- and insurance-based differences in access to inpatient rehabilitation after TBI, controlling for patient- and hospital-level variables. Patients with moderate to severe TBI aged 18-64 years with complete data on race and insurance status discharged alive from inpatient care were eligible for study. Among 307,675 TBI survivors meeting study criteria and potentially eligible for discharge to rehabilitation, 66% were white, 12% black, 15% Hispanic, 2% Asian, and 5% other ethnic minorities. Most whites (70%), Asians (70%), blacks (59%), and many Hispanics (49%) had insurance. Compared with insured whites, insured blacks had reduced odds of discharge to rehabilitation (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.75-0.95). Also, insured Hispanics (OR 0.52; 95% CI 0.44-0.60) and insured Asians (OR 0.54; 95% CI 0.39-0.73) were less likely to be discharged to rehabilitation than insured whites. Compared with insured whites, uninsured whites (OR 0.57; 95% CI 0.51-0.63), uninsured blacks (OR 0.33; 95% CI 0.26-0.42), uninsured Hispanics (OR 0.27; 95% CI 0.22-0.33), and uninsured Asians (OR 0.40; 95% CI 0.22-0.73) were less likely to be discharged to rehabilitation. Race and insurance are strong predictors of discharge to rehabilitation among adult TBI survivors in the United States. Efforts are needed to understand and eliminate disparities in access to rehabilitation after TBI.

Community integration after traumatic brain injury: a systematic review of the clinical implications of measurement and service provision for older adults

OBJECTIVE

To explore the scope, reliability, and validity of community integration measures for older adults after traumatic brain injury (TBI).

DATA SOURCES

A search of peer-reviewed articles in English from 1990 to April 2011 was conducted using the EBSCO Health and Scopus databases. Search terms included were community integration, traumatic brain injury or TBI, 65 plus or older adults, and assessment.

STUDY SELECTION

Forty-three eligible articles were identified, with 11 selected for full review using a standardized critical review method.

DATA EXTRACTION

Common community integration measures were identified and ranked for relevance and psychometric properties. Of the 43 eligible articles, studies reporting community integration outcomes post-TBI were identified and critically reviewed. Older adults' community integration needs post-TBI from high quality studies were summarized.

DATA SYNTHESIS

There is a relative lack of evidence pertaining to older adults post-TBI, but indicators are that older adults have poorer outcomes than their younger counterparts. The Community Integration Questionnaire (CIQ) is the most widely used community integration measurement tool used in research for people with TBI. Because of some limitations, many studies have used the CIQ in conjunction with other measures to better quantify and/or monitor changes in community integration.

CONCLUSIONS

Enhancing integration of older adults after TBI into their community of choice, with particular emphasis on social integration and quality of life, should be a primary rehabilitation goal. However, more research is needed to inform best practice guidelines to meet the needs of this growing TBI population. It is recommended that subjective tools, such as quality of life measures, are used in conjunction with well-established community integration measures, such as the CIQ, during the assessment process.

Tailoring work-life interventions for culturally diverse caregivers of patients with traumatic brain injury

With the increasing incidence of traumatic brain injury among culturally diverse families, there has also been increased attention to the dual demands of employment and caregiving. In this article, we contend that culturally diverse caregivers are an understudied group of workers. We examine literature to assist in conceptualizing the relationship between cultural orientation and caregiving, work-life stress, and organizational responses. Implications for strengthening the cultural responsiveness of work-life initiatives are discussed.

Perceptions of community integration in an ethnically diverse sample

OBJECTIVE

To investigate the meaning of community integration in an ethnically diverse sample.

DESIGN

Prospective study using mixed qualitative and quantitative methods.

SETTING

County level I trauma center.

PARTICIPANTS

Fifty-eight blacks, 57 Hispanics, and 52 whites with traumatic brain injury living in the community 6 months postinjury.

MAIN MEASURES

Open-ended interview questions and a questionnaire assessing perceived importance of community integration activities.

RESULTS

Resulting themes indicated that feeling part of the community was related to type and quality of community relationships, perceived safety and security, active involvement, feeling included and respected, and familiarity with the community. Themes regarding barriers included the following: environmental and social barriers; injury-related cognitive and physical changes; dissimilarities to others; relocation; and financial issues. Blacks and Hispanics placed more emphasis on domestic activities than did whites.

CONCLUSIONS AND IMPLICATIONS

Feeling integrated into the community relates to aspects of the environment as much as to involvement in specific activities. Environmental barriers can be just as important as injury-related changes. Different racial/ethnic groups place different value on participation activities. The results emphasize the importance of assessing subjective aspects of community integration, individualizing rehabilitation goals, and intervening in the environment to facilitate participation.

Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center

OBJECTIVE

To evaluate the potential influence of acute intoxication and dependence to alcohol on extrautilisation of health care resources by ethnic minority trauma patients in a level I trauma center.

METHODS

We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/nondependent(NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier.

RESULTS

Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2–2.8) and I/D patients (RR: 2.4, 95% CI: 1.6–3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU)was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models,did not change the results and conclusions.

DISCUSSION

Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

What is community integration anyway?: defining meaning following traumatic brain injury

Full community integration, or participation in society, is the ultimate goal of rehabilitation and of research conducted in the field of rehabilitation for persons with traumatic brain injury (TBI). Community integration has been traditionally defined by 3 main areas: employment or other productive activity, independent living, and social activity. However, these have not always received equal weighting and attention in clinical or research efforts. Significant gaps remain in our understanding of factors that impact community integration and in our ability to intervene to improve participation for persons with TBI. This article describes 3 main challenges for researchers and rehabilitation professionals. First, a comprehensive meaning of community integration is needed, which includes the viewpoints and preferences of persons with TBI. Second, cultural competence in measurement and intervention is needed. Third, a thorough assessment of environmental factors impacting participation is needed and should be incorporated into research and treatment planning.

Traumatic brain injury and long-term quality of life: findings from an Australian study

Recent calls have been made for the inclusion of health-related quality of life (HRQoL) in traumatic brain injury studies. This study reports the impact of TBI on traditional measures (general health, depression, social isolation, labor force participation), self-assessed health function status using the SF-36 version 2 (SF-36V2), and self-assessed health preference using two generic utility instruments, the assessment of quality of life (AQoL) and the SF6D. A random sample of TBI cases (n = 66) was drawn from a trauma registry and matched (gender, age, education, and relationship status) with non-trauma-exposed cases from a population health survey. All participants were interviewed and the two cohorts compared. When compared with matched comparators, TBI cases experienced worse general health, elevated probabilities of depression, social isolation, and worse labor force participation rates. The TBI-cohort reported worse health status on the SF-36V2. The most affected areas were social function, role emotion, and mental health (effect sizes -0.70 to -0.86). The reported utility values indicative of a HRQoL between 13 and 24% worse than their non-TBI contemporaries (effect sizes -0.80 to -0.81). The findings suggest that TBI has long-term consequences across all aspects of peoples' lives, and that these consequences can be self-assessed using generic instruments. The challenge is to provide and evaluate long-term services targeted at the life areas that those with TBI find particularly difficult.

Race\ethnicity and outcome after traumatic brain injury at a single, diverse center

BACKGROUND

Many factors may predict mortality and disability after traumatic brain injury (TBI), including age and injury severity. However, the role of race\ethnicity has typically been studied tangentially or in homogeneous settings. We investigated whether race\ethnicity was associated with medical outcomes at a single, diverse center.

METHODS

We retrospectively identified patients with TBI older than 17 years with blunt injuries admitted to a Level I trauma center from 2001 to 2004. Glasgow Outcome Scale (GOS) was used to determine outcome at discharge. We performed multivariable logistic regression on two measures of outcome by dichotomizing Glasgow Outcome Scale scores.

RESULTS

We identified 357 patients with TBI from five categories: whites (46.2%), Asians (19.9%), Hispanics (17.9%), blacks (10.9%), and other\unknown (5.0%). Without adjusting for other factors, Asians experienced higher mortality (odds ratio [OR] = 2.25, p = 0.01) compared with whites but not degree of disability. After adjusting for age and Injury Severity Score, a weaker trend remained for higher mortality in Asians (OR = 1.38, p = 0.35), and after excluding cases of assault, the finding was again significant (OR = 2.00, p = 0.04). We also confirmed the recently reported OR of higher mortality among blacks (OR = 1.30). Hispanics seemed to do slightly better at discharge.

CONCLUSIONS

The question of whether and how race plays a role in TBI is controversial. At a single, diverse center, we found that mortality is associated with race, age, and Injury Severity Score. Future clinical studies will benefit from detailed genotypic and phenotypic data and should balance larger sample sizes with ethnic diversity.

Traumatic brain injury and functional outcomes: Does minority status matter?

OBJECTIVES

(1) to determine differences between minorities vs. non-minorities on demographic, injury and rehabilitation characteristics and functional outcomes at admission, discharge and 1-year post-injury and (2) to examine differences in functional outcome at 1-year post-injury among (African-Americans, Hispanics and Whites).

DESIGN

Retrospective study.

SETTING

Longitudinal data were extracted from the TBI Model Systems database.

PARTICIPANTS

4929 individuals with moderate-to-severe TBI (3354 Whites vs. 1575 Minorities: 1207 African-Americans and 368 Hispanics) hospitalized between 1989-2004.

MAIN OUTCOME MEASURES

Functional outcomes at 1-year post-injury (Disability Rating Scale, Functional Independence Measure, Glasgow Outcome Scale-Extended and Community Integration Questionnaire).

RESULTS

At discharge and 1-year post-injury, minorities had poorer functional outcomes compared with Caucasians on all measures. After controlling for sociodemographic, injury and functional characteristics at admission, Hispanics and African-Americans still showed worse functional outcomes at 1-year post-injury compared with Whites on the DRS, FIM and CIQ. There were no significant differences between African Americans and Hispanics.

CONCLUSIONS

Minorities had significantly reduced long-term functional outcome after rehabilitation relative to Whites. It is imperative that rehabilitation professionals' consider factors related to poorer long-term functional outcome and work to improve the quality of life of minorities with TBI.

Traumatic brain injury and forensic neuropsychology

As part of a special issue of The Journal of Head Trauma Rehabilitation, forensic neuropsychology is reviewed as it applies to traumatic brain injury (TBI) and other types of acquired brain injury in which clinical neuropsychologists and rehabilitation psychologists may be asked to render professional opinions about the neurobehavioral effects and outcome of a brain injury. The article introduces and overviews the topic focusing on the process of forensic neuropsychological consultation and practice as it applies to patients with TBI or other types of acquired brain injury. The emphasis is on the application of scientist-practitioner standards as they apply to legal questions about the status of a TBI patient and how best that may be achieved. This article introduces each topic area covered in this special edition.