Validation of the quality of life after brain injury in Chinese persons with traumatic brain injury in Taiwan

Effects of Age, Sex, and Postconcussive Symptoms on Domain-Specific Quality of Life a Year After Mild Traumatic Brain Injury

OBJECTIVE

To identify the factors influencing longitudinal changes in patients' scores across 6 domains of the Quality of Life after Brain Injury (QOLIBRI) instrument 1 year after mild traumatic brain injury (mTBI).

DESIGN

This was a longitudinal cohort study.

PARTICIPANTS AND SETTING

Eligible patients with a new diagnosis of mTBI were recruited from the outpatient clinics of the neurosurgery departments of 3 teaching hospitals in Taipei City, Taiwan. In total, 672 patients participated in the baseline assessment. Postinjury follow-up was conducted at 6 and 12 months.

MAIN OUTCOME MEASURE

Six domains of the 37-item QOLIBRI: Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems.

RESULTS

Linear mixed-effects analyses revealed that, among patients younger than 60 years, the scores of the Cognition, Self, Daily Life and Autonomy, and Social Relationships domains significantly increased 6 months after injury; furthermore, their scores of the Cognition, Self, and Daily Life and Autonomy significantly increased 12 months after injury. By contrast, among patients 60 years and older, the scores of these domains reduced from baseline to 6 and 12 months. No significant sex-based difference was observed in the changes in scores of any QOLIBRI domain. At 6 and 12 months post-injury, the scores of the Cognition, Emotions, and Physical Problems domains were significantly higher for patients with postconcussive symptoms than for those without these symptoms.

CONCLUSIONS

Although multiple characteristics of patients significantly affected their baseline scores on the 6 domains of the QOLIBRI, only age and postconcussive symptoms were significantly associated with longitudinal changes in their scores 6 and 12 months after mTBI.

Psychometric properties and factor structure of the traditional Chinese version of the Community Integration Questionnaire-Revised in traumatic brain injury survivors

This study aimed to translate and validate the traditional Chinese version of the Community Integration Questionnaire-Revised (TC-CIQ-R) in patients with traumatic brain injury (TBI). We included participants aged ≥20 years and diagnosed as having TBI for ≥6 months from neurosurgical clinics. The 18-item TC-CIQ-R, Participation Measure - 3 Domains, 4 Dimensions (PM-3D4D), Extended Glasgow Outcome Scale (GOSE), and Taiwanese Quality of Life After Brain Injury (TQOLIBRI) were completed. The sample included 180 TBI survivors (54% male, mean age 47 years) of whom 87% sustained a mild TBI. Exploratory factor analysis extracted four factors - home integration, social integration, productivity, and electronic social networking - which explained 63.03% of the variation, after discarding the tenth item with a factor loading of 0.25. For criterion-related validity, the TC-CIQ-R was significantly correlated with the PM-3D4D; convergent validity was exhibited by demonstrating the associations between the TC-CIQ-R and TQOLIBRI. Known-group validity testing revealed significant differences in the subdomain and total scores of the TC-CIQ-R between participants with a mean GOSE score of ≤6 and >7 (all P  < 0.001). The TC-CIQ-R exhibited acceptable Cronbach's α values (0.68-0.88). We suggest the 17-item TC-CIQ-R as a valid tool for rehabilitation professionals, useful for both clinical practice and research in assessing community integration levels following TBI.

Life After Traumatic Brain Injury: Effects on the Lifestyle and Quality of Life of Community-Dwelling Patients

Persons who have experienced traumatic brain injury (TBI) may encounter a range of changes in their physical, mental, and cognitive functions as well as high fatigue levels. To gain a comprehensive understanding of the challenges faced by persons after TBI, we conducted multi-domain assessments among community-dwelling persons with a history of TBI and compared them with age- and sex-matched controls from the Northeastern Taiwan Community Medicine Research Cohort between 2019 and 2021. A total of 168 persons with TBI and 672 non-TBI controls were not different in terms of demographics, comorbidities, and physiological features. However, compared with the non-TBI group, the TBI group had a distinct lifestyle that involved increased reliance on analgesics (6.9% vs. 15.0%, respectively; p = 0.001) and sleep aids (p = 0.008), which negatively affected their quality of life. Moreover, they consumed more coffee (p < 0.001), tea (p < 0.001), cigarettes (p = 0.002), and betel nuts (p = 0.032) than did the non-TBI group. Notably, the use of coffee had a positive effect on the quality of life of the TBI group (F = 4.034; p = 0.045). Further, compared with the non-TBI group, the TBI group had increased risks of sarcopenia (p = 0.003), malnutrition (p = 0.003), and anxiety (p = 0.029) and reduced blood levels of vitamin D (29.83 ± 10.39 vs. 24.20 ± 6.59 ng/mL, respectively; p < 0.001). Overall, the TBI group had a reduced health-related quality of life, with significant challenges related to physical health, mental well-being, social interactions, pain management, and fatigue levels. Moreover, the TBI group experienced poorer sleep quality and efficiency than did the non-TBI group. In conclusion, persons who have sustained brain injuries that require comprehensive and holistic care that includes lifestyle modification, mental and physical healthcare plans, and increased long-term support from their communities. ClinicalTrials.gov (identifier: NCT04839796).

Effects of Neurofeedback on Cognitive Function, Productive Activity, and Quality of Life in Patients With Traumatic Brain Injury: A Randomized Controlled Trial

BACKGROUND

Cognitive impairment is common in patients with traumatic brain injury (TBI). Studies that have examined the effectiveness of neurofeedback (NFB) on cognitive function following TBI have had poor study designs and small sample sizes.

OBJECTIVES

This randomized controlled trial assessed the effects of low-resolution tomography Z-score NFB (LZNFB) and theta/beta NFB on cognitive impairment, return to productive activity, and quality of life in patients with TBI.

METHODS

We randomly assigned 87 patients with TBI with cognitive impairment to LZNFB, theta/beta NFB, or usual care (UC) groups. Patients in both NFB groups received weekly 60-minute treatment for 10 weeks, and those in the control group received UC and telephone interviews for 10 weeks. The primary outcome was cognitive function as measured by performance on cognitive tasks; the secondary outcomes included productive activity and quality of life based on the Community Integration Questionnaire-revised (CIQ-R) and the Quality of Life after Brain Injury (QOLIBRI), respectively, at baseline and immediately after the last intervention.

RESULTS

The LZNFB group exhibited significantly greater improvements in immediate recall, delayed recall, recognition memory, and selective attention compared with the UC group; the theta/beta NFB group exhibited improvements in only immediate memory and selective attention (P < .05). The total CIQ-R scores of the LZNFB group after treatment were significantly improved than those of the UC group were.

CONCLUSION

Consecutive LZNFB achieved therapeutic effects in memory, attention, and productive activity, whereas theta/beta NFB improved memory and attention in patients with TBI.This trial was prospectively registered at ClinicalTrial.gov (registration number: NCT03515317; https://clinicaltrials.gov/ct2/show/NCT03515317).

Postconcussion Symptoms After an Uncomplicated Mild Traumatic Brain Injury in Older Adults: Frequency, Risk Factors, and Impact on Quality of Life

BACKGROUND

Postconcussion symptoms (PCSs) are common complaints reported by patients after a mild traumatic brain injury (TBI), and these symptoms may lower quality of life. Previous investigations have primarily focused on PCSs in children, adults, and athletes. The frequency, and risk factors, and effects of PCSs for older adults with mild TBIs are unclear.

PURPOSE

To investigate the frequency and risk factors of PCSs, and investigate their effects on quality of life over time after mild TBI in older adults.

METHODS

A prospective longitudinal study was performed. All participants were enrolled from the emergency department or neurosurgical outpatient clinics of a medical center. The measurement tools were the Rivermead Post-Concussion Symptoms Questionnaire and the Quality of Life after Traumatic Brain Injury. Measurements were performed on the seventh day, at the first month, and at the sixth month after the head injury. A generalized estimating equation model was used for data analyses.

RESULTS

One hundred and one older adults (mean age of 76.0 years) with mild TBIs with negative neuroimaging findings were included. Overall, 32.7%, 4%, and 15.8% of the sample reported PCS after 7 days, 1 month, and 6 months of head injury, respectively, revealing a U-shaped trend. We observed that comorbidity measured using the modified Charlson Comorbidity Index was associated with differences in PCSs ( P < .05). PCSs were an independent predictor of changes in postinjury quality of life ( P < .001).

CONCLUSIONS

The results indicate that PCS after a mild TBI in older adults is prevalent, even in the chronic phase after a TBI, and PCSs significantly affected the quality of life of our cohort. Therefore, to improve patient quality of life, healthcare providers should employ effective interventions to manage PCSs at different phases after a TBI.

Comparing the Quality of Life after Brain Injury-Overall Scale and Satisfaction with Life Scale as Outcome Measures for Traumatic Brain Injury Research

It is important to measure quality of life (QoL) after traumatic brain injury (TBI), yet limited studies have compared QoL inventories. In 2579 TBI patients, orthopedic trauma controls, and healthy friend control participants, we compared the Quality of Life After Brain Injury-Overall Scale (QOLIBRI-OS), developed for TBI patients, to the Satisfaction with Life Scale (SWLS), an index of generic life satisfaction. We tested the hypothesis that group differences (TBI and orthopedic trauma vs. healthy friend controls) would be larger for the QOLIBRI-OS than the SWLS and that the QOLIBRI-OS would manifest more substantial changes over time in the injured groups, demonstrating more relevance of the QOLIBRI-OS to traumatic injury recovery. (1) We compared the group differences (TBI vs. orthopedic trauma control vs. friend control) in QoL as indexed by the SWLS versus the QOLIBRI-OS and (2) characterized changes across time in these two inventories across 1 year in these three groups. Our secondary objective was to characterize the relationship between TBI severity and QoL. As compared with healthy friend controls, the QOLIBRI reflected greater reductions in QoL than the SWLS for both the TBI group (all time points) and the orthopedic trauma control group (2 weeks and 3 months). The QOLIBRI-OS better captured expected improvements in QoL during the injury recovery course in injured groups than the SWLS, which demonstrated smaller changes over time. TBI severity was not consistently or robustly associated with self-reported QoL. The findings imply that, as compared with the SWLS, the QOLIBRI-OS appears to identify QoL issues more specifically relevant to traumatically injured patients and may be a more appropriate primary QoL outcome measure for research focused on the sequelae of traumatic injuries.

Quality of life after traumatic brain injury: a cross-sectional analysis uncovers age- and sex-related differences over the adult life span

Traumatic brain injury (TBI) is the leading cause of disability in the working population and becomes increasingly prevalent in the elderly. Thus, TBI is a major global health burden. However, age- and sex-related long-term outcome regarding patient’s health-related quality of life (HRQoL) is yet not clarified. In this cross-sectional study, we present age- and sex-related demographics and HRQoL up to 10 years after TBI using the Quality of Life after Brain Injury (QOLIBRI) instrument. The QOLIBRI total score ranges from zero to 100 indicating good (≥ 60), moderate (40–59) or unfavorable (< 40) HRQoL. Two-thirds of the entire chronic TBI cohort (102 males; 33 females) aged 18–85 years reported good HRQoL up to 10 years after TBI. TBI etiology differed between sexes with females suffering more often from traffic- than fall-related TBI (p = 0.01) with increasing prevalence during aging (p = < 0.001). HRQoL (good/moderate/unfavorable) differed between sexes (p < 0.0001) with 17% more females reporting moderate outcome (p = 0.01). Specifically, older females (54–76-years at TBI) were affected, while males constantly reported good HRQoL (p = 0.017). Cognition (p = 0.014), self-perception (p = 0.009), and emotions (p = 0.016) rather than physical problems (p = 0.1) constrained older females’ HRQoL after TBI. Experiencing TBI during aging does not influence HRQoL outcome in males but females suggesting that female brains cope less well with a traumatic injury during aging. Therefore, older females need long-term follow-ups after TBI to detect neuropsychiatric sequels that restrict their quality of life. Further investigations are necessary to uncover the mechanisms of this so far unknown phenomenon.

Comparison of Four Quality of Life Inventories for Patients with Traumatic Brain Injuries and Orthopedic Injuries

The value of assessing health-related quality of life (HRQoL) in traumatic brain injury (TBI) patients has been increasingly recognized in recent years. Yet, research examining generic and TBI-specific quality of life (QOL) methodologies within this population has been limited, rendering decisions to use one alternative over another difficult and based largely on conceptual grounds. The current study compared widely used generic QoL/HRQOL measures (Satisfaction With Life Scale, 36-item Short Form Survey) and newer population-specific HRQoL measures (Quality of Life after Brain Injury [QOLIBRI], Trauma-Quality of Life [TQoL]) among 77 TBI and 23 orthopedically injured trauma control patients. The QOLIBRI Cognition and Physical Problems subscales were the only HRQoL scores across the four instruments administered that differentiated between patient groups: participants with TBI reported being significantly less satisfied with their cognitive abilities and more bothered by physical problems. Analyses of the unique population-specific QOLIBRI content revealed that 12.2-31.5% of TBI patients endorsed dissatisfaction and 28.8-51.4% endorsed being bothered by items unique to the QOLIBRI. Endorsement rates for unique TQoL items ranged from 1.4-75.7%. Overall, the QOLIBRI and TQoL appear to capture important information pertinent to patients with TBI and trauma. Inclusion of these disease-specific HRQoL measures is recommended over the use of only generic measures among TBI populations.

Psychometric Comparisons of the Quality of Life after Brain Injury between Individuals with Mild and Those with Moderate/Severe Traumatic Brain Injuries

This study compared psychometric properties of the Taiwanese version of the Quality of Life after Brain Injury (QOLIBRI) between patients with mild and those with moderate/severe traumatic brain injury (TBI). Of 683 participants, 548 had sustained a mild injury with Glasgow Coma Scale (GCS) scores of 13-15, and 135 had a moderate/severe injury with GCS scores of 3-12. The QOLIBRI comprises six domains: Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems. Results of the Rasch analysis showed that two items of "Problems with seeing/hearing" and "Finding one's way about" were underfitting in the mild TBI group while the item "Problems with seeing/hearing" was underfitting and the item "TBI effects" was overfitting in the moderate/severe TBI group. The largest differential item functioning (DIF) between the mild and moderate/severe TBI groups appeared in the item "Energy," followed by those of "Being slow/clumsy" and "Problems with seeing/hearing." For both the mild and moderate/severe TBI groups, the two domains of Emotions and Physical Problems displayed strong ceiling effects, low person reliability and separation, and an incomplete range of the person measure covered by the item difficulty, while the remaining four domains had acceptable performances. While the psychometric performance of the QOLIBRI at the domain level was similar between the mild and moderate/severe TBI groups, certain items exhibited different functioning between the two groups. The reason why the two domains of the Emotions and Physical Problems performed poorly in the two TBI severity groups could be due to cross-cultural effects. The meanings of these DIF items, particularly for patients with a mild TBI, and factors contributing to the ceiling effect of the Emotions and Physical Problems domains in other ethnic Chinese populations need to be investigated further.

Validating the Quality of Life After Brain Injury Through Rasch Analysis

OBJECTIVE

The Quality of Life after Brain Injury (QOLIBRI), a cross-cultural instrument, has been validated in several languages; however, traditional psychometric approaches have critical limitations. Therefore, we applied the Rasch model for validating the 37-item QOLIBRI scale among a Chinese population with traumatic brain injury.

PARTICIPANTS AND SETTING

In total, 587 participants (mean age: 44.2 ± 15.4 years; women, 46.3%) were surveyed in neurosurgery departments at 6 hospitals in Taipei, Taiwan.

MAIN OUTCOME MEASURE

The QOLIBRI.

RESULTS

Of the 6 subscales of the QOLIBRI, 4 (cognition, self, daily life and autonomy, and social relationships) were unidimensional, valid, and reliable, whereas the remaining 2 (emotions and physical problems) exhibited poor unidimensionality, item and person reliability, and person-item targeting. Five items (energy, concentrating, getting out and about, sex life, and achievements) showed considerable differential item functioning among age groups, disability levels, and time since traumatic brain injury.

CONCLUSION

According to item response theory, we identified psychometric issues in the emotions and physical problems subscales of the QOLIBRI as well as several differential item functioning items. Future research is required to determine whether similar results are observed in other language versions of the QOLIBRI or in other countries.

Validation of the QOLIBRI - Quality of Life after Brain Injury questionnaire in patients after TBI in Israel

BACKGROUND

The QOLIBRI - Quality of Life after Brain Injury questionnaire was developed by the QOLIBRI Task Force (QTF). Our goal was to investigate the applicability, validity and reliability of the QOLIBRI in Israel.

METHODS

Validation of the Hebrew questionnaire was performed after it had been administered to 128 adults with traumatic brain injury (TBI), who were between 3 months' and 15 years' post-discharge from rehabilitation.

RESULTS

The internal consistency of the QOLIBRI subscales with the QOLIBRI Total scale was high (Cronbach's α = 0.92); the same was true regarding the correlations between each QOLIBRI subscale and its own items (α = 0.92-0.95). Significant and high Pearson's and Spearman's correlations of the QOLIBRI subscales with demographic and clinical characteristics of the GOSE, ADL, HADS, SF-36, and various aspects of self-reported health status were found. Factor analyses (FA) were applied to confirm the validity of the Hebrew version, using the maximum likelihood method. The six subscales explained 100% of the variance.

CONCLUSION

The Hebrew version of the QOLIBRI was found to be useful, meaningful and meeting psychometric criteria in persons after TBI in Israel. The findings support the cross-cultural applicability of the QOLIBRI, regardless of cultural and social differences.

Assessment of Health-Related Quality of Life after TBI: Comparison of a Disease-Specific (QOLIBRI) with a Generic (SF-36) Instrument

Psychosocial, emotional, and physical problems can emerge after traumatic brain injury (TBI), potentially impacting health-related quality of life (HRQoL). Until now, however, neither the discriminatory power of disease-specific (QOLIBRI) and generic (SF-36) HRQoL nor their correlates have been compared in detail. These aspects as well as some psychometric item characteristics were studied in a sample of 795 TBI survivors. The Shannon H (') index absolute informativity, as an indicator of an instrument's power to differentiate between individuals within a specific group or health state, was investigated. Psychometric performance of the two instruments was predominantly good, generally higher, and more homogenous for the QOLIBRI than for the SF-36 subscales. Notably, the SF-36 "Role Physical," "Role Emotional," and "Social Functioning" subscales showed less satisfactory discriminatory power than all other dimensions or the sum scores of both instruments. The absolute informativity of disease-specific as well as generic HRQoL instruments concerning the different groups defined by different correlates differed significantly. When the focus is on how a certain subscale or sum score differentiates between individuals in one specific dimension/health state, the QOLIBRI can be recommended as the preferable instrument.

Suitability of the Quality of Life after Brain Injury Instrument for Older People with Traumatic Brain Injury

We prospectively investigated the psychometric properties of the Quality of Life after Brain Injury (QOLIBRI) instrument among older patients with traumatic brain injury (TBI). The 37-item QOLIBRI comprises six domains (cognition, self, daily life and autonomy, social relationships, emotions, and physical problems). We recruited 333 patients ≥60 years of age with TBI from the neurosurgery clinics and emergency departments of three hospitals in Taipei, Taiwan. The ceiling and floor values for most QOLIBRI domains were <5%, and the internal consistency and test-retest reliability ranged from 0.84 to 0.97 and 0.83 to 0.96, respectively. For the known-groups validity, patients with TBI attained lower scores for all QOLIBRI domains, except physical problems, compared with those with soft-tissue injuries. Patients with intact cognition who had higher levels on the Glasgow Outcome Scale Extended (GOSE) and the Glasgow Coma Scale, fewer limitations in activities of daily living, and fewer chronic conditions obtained higher scores for almost all the QOLIBRI domains, compared with their counterparts. For convergent validity, the correlation coefficients for the QOLIBRI domains and the selected functional measures conceptually related to that domain were all ≥0.4. A confirmatory factor analysis revealed that the original six-domain structure fit the data with a comparative fit index of ≥0.9. Effect sizes for changes in the GOSE over a 6-month follow-up period were clinically meaningful (≥ 0.2) for all the QOLIBRI domains except emotions. For older people with TBI, the use of the QOLIBRI is generally appropriate, and adding the domain of environment to the scale would be beneficial.

Trajectories and associated factors of quality of life, global outcome, and post-concussion symptoms in the first year following mild traumatic brain injury

PURPOSE

To investigate the associated factors and change trajectories of quality of life (QoL), global outcome, and post-concussion symptoms (PCS) over the first year following mild traumatic brain injury (mTBI).

METHODS

This was a prospective longitudinal study of 100 participants with mTBI from neurosurgical outpatient departments in Chiayi County District Hospitals in Taiwan. The checklist of post-concussion syndromes (CPCS) was used to assess PCS at enrollment and at 1, 3, and 12 months after mTBI; the glasgow outcome scale extended (GOSE), the quality of life after brain injured (QOLIBRI), Chinese version, and the Short Form 36 Health Survey (SF-36), Taiwan version, were used to assess mTBI global outcome and QoL at 1, 3, and 12 months after mTBI.

RESULTS

Latent class growth models (LCGMs) indicated the change trajectories of QOLIBRI, PCS SF-36, MCS SF-36, GOSE, and PCS. Classes of trajectory were associated with age ≥40 years, unemployment at 1 month after injury, and educational level ≤12 years. Univariate analysis revealed that employment status at 1 month post-injury was correlated with the trajectories of QOLIBRI, PCS SF-36, MCS SF-36, and GOSE, but not PCS.

CONCLUSIONS

Employment status was the most crucial associated factor for QoL in individuals with mTBI at the 1-year follow-up. Future studies should explore the benefits of employment on QoL of individuals with mTBI.

Health-related quality of life after TBI: a systematic review of study design, instruments, measurement properties, and outcome

Measurement of health-related quality of life (HRQL) is essential to quantify the subjective burden of traumatic brain injury (TBI) in survivors. We performed a systematic review of HRQL studies in TBI to evaluate study design, instruments used, methodological quality, and outcome. Fifty-eight studies were included, showing large variation in HRQL instruments and assessment time points used. The Short Form-36 (SF-36) was most frequently used. A high prevalence of health problems during and after the first year of TBI was a common finding of the studies included. In the long term, patients with a TBI still showed large deficits from full recovery compared to population norms. Positive results for internal consistency and interpretability of the SF-36 were reported in validity studies. The Quality of Life after Brain Injury instrument (QOLIBRI), European Brain Injury Questionnaire (EBIQ), Child Health Questionnaire (CHQ), and the World Health Organization Quality of Life short version (WHOQOL-BREF) showed positive results, but evidence was limited. Meta-analysis of SF-36 showed that TBI outcome is heterogeneous, encompassing a broad spectrum of HRQL, with most problems reported in the physical, emotional, and social functioning domain. The use of SF-36 in combination with a TBI-specific instrument, i.e., QOLIBRI, seems promising. Consensus on preferred methodologies of HRQL measurement in TBI would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of the burden of TBI.