Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder

BACKGROUND

Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear.

METHODS

We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings.

RESULTS

Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms.

CONCLUSIONS

In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.

Perceived health, caregiver burden, and quality of life in women partners providing care to Veterans with traumatic brain injury

Families of Veterans with traumatic brain injury (TBI) are often faced with providing long-term informal care to their loved one. However, little is known about how their perceived health and caregiving burden contribute to their quality of life (QOL). The purpose of this descriptive study was to describe perceived health, somatic symptoms, caregiver burden, and perceived QOL and to identify the extent to which these variables are associated with QOL in female partners/spouses of Veterans with TBI. Participants completed a written questionnaire including the Patient Health Questionnaire-15, Caregiver Reaction Assessment, Quality of Life Index, and the general health subscale of the 12-Item Short Form Survey version 2. Caregivers reported moderate levels of QOL, and over a quarter of the sample reported high levels of somatic symptoms, particularly fatigue and sleep disturbance. Age, perceived general health, somatic symptoms, the five subscales of caregiver burden (self-esteem, disrupted schedule, effect on finances, lack of family support, and effect on health) predicted QOL and explained 64% of its variance (adjusted r² = 0.64, F(8,31) = 9.59). However, only somatic symptoms and the caregiver burden subscales of self-esteem and effect on finances were significant predictors in the model. These findings have implications for development of family-centered interventions to enhance the QOL of informal caregivers of Veterans with TBI.

Responsiveness, Minimal Detectable Change, and Minimally Clinically Important Differences for the Disorders of Consciousness Scale

OBJECTIVES

To determine the responsiveness, minimal detectable change (MDC95), and minimally clinically important difference (MCID) of the Disorders of Consciousness Scale (DOCS-25) in patients with severe traumatic brain injury (TBI) and to report the percentages of patients' change scores exceeding MDC and MCID after 3 weeks of inpatient rehabilitation.

SETTING

Post-acute rehabilitation hospitals.

PARTICIPANTS

One hundred seventy-two patients with severe TBI. Ninety-two were included in the DOCS-25 3-week analysis.

DESIGN

Retrospective cohort study.

MAIN MEASURE(S)

Disorders of Consciousness Scale, Glasgow Coma Scale.

RESULTS

The effect size and standardized response mean of the DOCS-25 for those who improved were 0.45 and 1.3, respectively-moderate to large by Cohen criteria. The MDC95 (95% confidence interval) was 5.6. Distribution-based MCIDs for small (0.20 SD), moderate (0.33 SD), and large (0.50 SD) differences were 2.6 units, 4.4 units, and 6.6 units, respectively. The anchor-based MCID was 8.6 units. On average, patients who improved (n = 57) gained 14.5 units by week 3, exceeding the anchor-based MCID. On average, patients who did not improve (n = 35) declined by 7.2 units, which exceeds both the MDC95 and the largest distribution-based MCID.

CONCLUSION(S)

The DOCS-25 is a responsive, clinician-observed assessment tool for capturing change in neurobehavioral function in adults recovering from severe TBI. This is the first study to provide evidence for the size of neurobehavioral function change that might indicate meaningful recovery in patients with severe TBI. Results from this study may support future research by better informing sample size calculations for clinical trials and also assist clinicians in identifying when variation in level of consciousness is consequential enough to warrant changes in intervention.

Exploring the Relationship Between Mild Traumatic Brain Injury Exposure and the Presence and Severity of Postconcussive Symptoms Among Veterans Deployed to Iraq and Afghanistan

OBJECTIVE

The aim of this study was to describe the association between mild traumatic brain injury (mTBI) and persisting postconcussive symptoms according to symptom category, number, and severity.

DESIGN

The study design was observational.

PARTICIPANTS

The study sample comprised veterans (≥18 years of age) deployed in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts who had not received any treatment for mTBI in the 30 days preceding study enrollment.

METHODS

Veterans were interviewed and completed testing in a single day. The Standard TBI Diagnostic Interview and the Clinician-Administered PTSD Scale were used. Testing included the Neurobehavioral Symptom Inventory and a full neuropsychological battery. Gold standard classification methods were utilized to determine presence/absence of mTBI. For each of the 5 symptom outcomes, an adjusted multiple linear regression model (negative binomial count models) accounting for effects of socio-demographic variables and behavioral health conditions was used.

MAIN OUTCOME MEASURES

Self-report of neurobehavioral symptoms categorized as affective, cognitive, somatic, and vestibular symptoms, in addition to the instruments specified above.

RESULTS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, were observed to have 30% more symptoms overall (P < .001), 34% more somatic symptoms (P < .001), 22% more cognitive symptoms (P = .008), 15% more affective symptoms (P = .017), and 59% more vestibular symptoms (P < .001). For adjusted models, variables significantly related to number of symptoms across all 4 symptom categories were anxiety (all P < .001) and insomnia (all P < .001). For the adjusted models, variables significantly related to symptom severity across all 4 symptom categories were insomnia (all P < .001), depression (P < .001-.05) and anxiety (all, P < .001).

CONCLUSIONS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, have significantly more and significantly more severe persisting symptoms, with vestibular symptoms reported with the greatest frequency. After accounting for behavioral health conditions and socio-demographic factors, OEF/OIF veterans with mTBI compared to veterans without mTBI had significantly more cognitive, affective, vestibular, and somatic symptoms persisting 4.8 years after the mTBI event(s).

Placebo-Controlled Trial of Familiar Auditory Sensory Training for Acute Severe Traumatic Brain Injury: A Preliminary Report

BACKGROUND

Sensory stimulation is often provided to persons incurring severe traumatic brain injury (TBI), but therapeutic effects are unclear.

OBJECTIVE

This preliminary study investigated neurobehavioral and neurophysiological effects related to sensory stimulation on global neurobehavioral functioning, arousal, and awareness.

METHODS

A double-blind randomized placebo-controlled trial where 15 participants in states of disordered consciousness (DOC), an average of 70 days after TBI, were provided either the Familiar Auditory Sensory Training (FAST) or Placebo of silence. Global neurobehavioral functioning was measured with the Disorders of Consciousness Scale (DOCS). Arousal and awareness were measured with the Coma-Near-Coma (CNC) scale. Neurophysiological effect was measured using functional magnetic resonance imaging (fMRI).

RESULTS

FAST (n = 8) and Placebo (n = 7) groups each showed neurobehavioral improvement. Mean DOCS change (FAST = 13.5, SD = 8.2; Placebo = 18.9, SD = 15.6) was not different, but FAST patients had significantly (P = .049; 95% confidence interval [CI] = -1.51, -.005) more CNC gains (FAST = 1.01, SD = 0.60; Placebo = 0.25, SD = 0.70). Mixed-effects models confirm CNC findings (P = .002). Treatment effect, based on CNC, is large (d = 1.88, 95% CI = 0.77, 3.00). Number needed to treat is 2. FAST patients had more fMRI activation in language regions and whole brain (P values <.05) resembling healthy controls' activation.

CONCLUSIONS

For persons with DOC 29 to 170 days after TBI, FAST resulted in CNC gains and increased neural responsivity to vocal stimuli in language regions. Clinicians should consider providing the FAST to support patient engagement in neurorehabilitation.

Prescribing multiple neurostimulants during rehabilitation for severe brain injury

BACKGROUND

Despite a lack of clear evidence, multiple neurostimulants are commonly provided after severe brain injury (BI). The purpose of this study is to determine if the number of neurostimulants received during rehabilitation was associated with recovery of full consciousness or improved neurobehavioral function after severe BI.

METHOD

Data from 115 participants were extracted from a neurobehavioral observational study database for this exploratory, retrospective analysis. Univariate optimal data analysis was conducted to determine if the number of neurostimulants influenced classification of four outcomes: recovery of full consciousness during rehabilitation, recovery of full consciousness within one year of injury, and meaningful neurobehavioral improvement during rehabilitation defined as either at least a 4.7 unit (minimal detectable change) or 2.58 unit (minimal clinically important difference) gain on the Disorders of Consciousness Scale-25 (DOCS-25).

RESULTS

Number of neurostimulants was not significantly (P > 0.05) associated with recovery of full consciousness during rehabilitation, within one year of injury, or meaningful neurobehavioral improvement using the DOCS-25.

CONCLUSIONS

Receiving multiple neurostimulants during rehabilitation may not influence recovery of full consciousness or meaningful neurobehavioral improvement. Given costs associated with additional medication, future research is needed to guide physicians about the merits of prescribing multiple neurostimulants during rehabilitation after severe BI.

Transcranial magnetic stimulation: potential treatment for co-occurring alcohol, traumatic brain injury and posttraumatic stress disorders

Alcohol use disorder (AUD), mild traumatic brain injury (mTBI), and posttraumatic stress disorder (PTSD) commonly co-occur (AUD + mTBI + PTSD). These conditions have overlapping symptoms which are, in part, reflective of overlapping neuropathology. These conditions become problematic because their co-occurrence can exacerbate symptoms. Therefore, treatments must be developed that are inclusive to all three conditions. Repetitive transcranial magnetic stimulation (rTMS) is non-invasive and may be an ideal treatment for co-occurring AUD + mTBI + PTSD. There is accumulating evidence on rTMS as a treatment for people with AUD, mTBI, and PTSD each alone. However, there are no published studies to date on rTMS as a treatment for co-occurring AUD + mTBI + PTSD. This review article advances the knowledge base for rTMS as a treatment for AUD + mTBI + PTSD. This review provides background information about these co-occurring conditions as well as rTMS. The existing literature on rTMS as a treatment for people with AUD, TBI, and PTSD each alone is reviewed. Finally, neurobiological findings in support of a theoretical model are discussed to inform TMS as a treatment for co-occurring AUD + mTBI + PTSD. The peer-reviewed literature was identified by targeted literature searches using PubMed and supplemented by cross-referencing the bibliographies of relevant review articles. The existing evidence on rTMS as a treatment for these conditions in isolation, coupled with the overlapping neuropathology and symptomology of these conditions, suggests that rTMS may be well suited for the treatment of these conditions together.

Predicting levels of independence with expressing needs and ideas 1 year after severe brain injury

PURPOSE/OBJECTIVE

Severe brain injury (BI) is a catastrophic event often evolving into a complex chronic and severely disabling condition making activity participation possible only with sustained caregiving. One aspect of building sustainable caregiving is early provision of information about expected outcomes germane to patients and their caregivers. An analysis was conducted to determine whether 2 levels of independence with expressing needs and ideas 1-year after severe BI could be predicted using variables available early after injury.

METHOD

The authors examined a subsample (n = 79) of participants of an outcome study who received repeated neurobehavioral evaluations with the Disorders of Consciousness Scale (DOCS) and who were assessed 1 year after injury with the Functional Independence Measures (FIM). Explanatory variables included DOCS measures, patient characteristics, coexisting conditions, and interventions. The outcome is measured with the FIM Expression item. Optimal data analysis was used to construct multivariate classification tree models.

RESULTS

The 2nd (p = .004) DOCS visual measure and seizure (p = .004) entered the final model providing 79% accuracy in classifying more or less independence with expressing needs and ideas at 1 year. The model will correctly identify 78% of future severe BI survivors who will have more independence and 82% of persons who will have less independence.

CONCLUSIONS

For persons incurring severe BI, it is possible to predict, early after injury, more and less independence with expressing needs and ideas 1-year after injury. This evidence is 1 contribution to a larger body of evidence needed to enable early caregiver education about recovery expectations in terms of patient functioning relative to caregiving needs, which in turn will help build sustainable caregiving for this population.

Psychometric properties of the disorders of consciousness scale

OBJECTIVE

To provide evidence for psychometric properties of the Disorders of Consciousness Scale (DOCS).

DESIGN

Prospective observational cohort.

SETTINGS

Seven rehabilitation facilities.

PARTICIPANTS

Patients (N=174) with severe brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE DOCS RESULTS

Initial analyses suggested eliminating 6 items to maximize psychometrics, resulting in the DOCS-25. The 25 items form a unidimensional hierarchy, rating scale categories are ordered, there are no misfitting items, and differential item functioning was not found according to sex, type of brain injury, veteran status, and days from onset. Person separation reliability (.91) indicates that the DOCS-25 is appropriate for individual patient measurement. Items are well targeted to the sample, with the difference between mean person and item calibrations less than 1 logit. DOCS-25 Rasch measures result in a 62% gain in relative precision over total raw scores. Internal consistency is very good (Cronbach α=.86); interrater agreement is excellent (intracIass correlation coefficient=.90) for both the DOCS-25 and the sensory subscales. The DOCS-25 total measure, but not subscale measures, correlates with the Glasgow Coma Scale and the Coma/Near-Coma Scales and distinguishes significantly between vegetative and minimally conscious states, indicating concurrent validity.

CONCLUSIONS

The DOCS-25 is psychometrically strong. It has excellent measurement precision and captures a broad range of patient function, which is critical for capturing recovery of consciousness. The sensory subscales are clinically informative but should not be reported as separate measures. The Keyform synthesizes clinical observations to visualize response patterns with potential for informing clinical decision-making. Future studies should determine sensitivity to change, examine issues of rater severity, and explore the usefulness of the Keyform in clinical practice.

Caregiving experiences and health conditions of women veteran and non-veteran caregivers

BACKGROUND

Unique experiences, for example, trauma, of women veteran caregivers may create differences in the caregiving experience and may be associated with health concerns. We examined caregiving factors and health concerns in women veteran caregivers compared to non-veteran women (civilian) caregivers, and identified variables associated with being a woman veteran caregiver.

METHODS

We conducted secondary data analyses using data from a multistate survey to examine sociodemographics, the caregiver experience (relationship to recipient, duration as caregiver, hours of care provided, area help is needed, and greatest difficulty faced as a caregiver); emotional support; life satisfaction; lifestyle behaviors; general, physical, and mental health; and chronic conditions in women informal caregivers.

FINDINGS

Of women caregivers, more veteran caregivers provided activities of daily living (ADL) help (33%) than non-veteran caregivers (21%; p = .02). There were no differences in years as a caregiver, hours of care provided, or the relationship to the recipient. Poor sleep and poor mental health were experienced by more women veteran caregivers (vs. non-veteran), but physical health, general health, and chronic condition prevalence did not differ. Women veteran caregivers had twofold greater odds of being Black, never married, college educated, and providing ADL assistance. Odds of obesity were lower for women veteran caregivers relative to other women caregivers.

CONCLUSIONS

Women veteran caregivers experience health concerns, including sleeplessness, poor mental health, and some chronic conditions. Our cohort were young women, yet had concerns that may be exacerbated by being a veteran and assuming a caregiver role. Comprehensive services to support their needs as veteran patients and as caregivers are needed.

Medical comorbidities in disorders of consciousness patients and their association with functional outcomes

OBJECTIVE

To identify, for patients in states of seriously impaired consciousness, comorbid conditions present during inpatient rehabilitation and their association with function at 1 year.

DESIGN

Abstracted data from a prospective cross-sectional observational study with data collection occurring January 1996 through December 2007.

SETTING

Four inpatient rehabilitation facilities in metropolitan areas.

PARTICIPANTS

The study sample of 68 participants is abstracted from a database of 157 patients remaining in states of seriously impaired consciousness for at least 28 days.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

One-year cognitive, motor, and total FIM score.

RESULTS

The most common medical complications during inpatient rehabilitation for the study sample are active seizures (46%), spasticity (57%), urinary tract infections (47%), and hydrocephalus with and without shunt (38%). Presence of ≥3 medical complications during inpatient rehabilitation, controlling for injury severity, is significantly (P<.05) associated with poorer total FIM and FIM motor scores 1 year after injury. The presence of hydrocephalus with and without shunt (r=-.20, -.21, -.18; P ≤.15), active seizures (r=-.31, -.22, -.42), spasticity (r=-.38, -.28, -.40), and urinary tract infections (r=-.25, -.24, -.26) were significantly (P<.10) associated with total FIM, FIM cognitive, and FIM motor scores, respectively.

CONCLUSIONS

Reported findings indicate that persons in states of seriously impaired consciousness with higher numbers of medical complications during inpatient rehabilitation are more likely to have lower functional levels 1-year postinjury. The findings indicate that persons with ≥3 medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. It is, therefore, prudent to evaluate these patients for indications of these complications during inpatient rehabilitation.

Establishing a prognosis for functional outcome during coma recovery

PRIMARY OBJECTIVE

One of the most challenging tasks for clinicians caring for survivors of severe brain injury (BI) is establishing a prognosis, for long-term functional outcome, while the patient is unconscious. The objective of this article is to report findings regarding the prediction of functional outcomes 1-year after severe BI using data available when the patient is unconscious.

RESEARCH DESIGN

Longitudinal prognostication study.

METHODS AND PROCEDURES

Persons unconscious after severe BI who present to inpatient (IP) rehabilitation hospitals in the Midwestern US are enrolled in an ongoing study. Each subject is followed for 1-year and the final outcome interview includes approximately 70 questions; 32 of these questions are from the Craig Handicap Assessment and Reporting Technique (CHART). A sample of 63 persons was abstracted from the study database to examine the predictability of 42 independent variables and 16 dichotomous outcomes.

MAIN OUTCOMES AND RESULTS

Twelve of the 16 dichotomous outcomes were found to be significantly predictable (p < 0.05). These involve activity, participation, environment and quality of life outcomes. Ten predictors were found to be significant (p < 0.05): aetiology (Closed Head Injury vs. Other BI), presence of urinary tract infection (UTI), seizure, hypertension during IP rehabilitation, veteran benefit eligibility, health insurance, marital status at injury, whether or not recovery of consciousness occurred within 1 year, the number of days between injury and admission to acute rehabilitation and the average length of IP rehabilitation stay. Eight of the 10 variables are available early after injury or when the patient is unconscious.

Repetitive transcranial magnetic stimulation-associated neurobehavioral gains during coma recovery

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method to induce changes in cortical neural excitability. This report presents findings from the first participant of a safety and efficacy study that examined a therapeutic rTMS protocol for persons with severe traumatic brain injury (TBI).

OBJECTIVE

The primary hypothesis was that there will be no adverse events related to the provision of a 6-week rTMS protocol for persons with severe TBI who remain, at best, in a minimally conscious state for longer than 3 months. The secondary hypothesis was that the rTMS protocol would induce significant neurobehavioral gains during treatment and that these gains would persist at 6-week follow-up.

METHODS

A 6-week rTMS protocol (30 sessions) was delivered to a 26-year-old man who remained in a vegetative state 287 days after severe TBI. Stimulation was directed over the right dorsolateral prefrontal cortex. Repeated safety measures, neurobehavioral assessments, clinical examinations, and evoked potentials (EP) were obtained at baseline, every fifth rTMS session (weekly), and at a 6-week follow-up.

RESULTS

There were no adverse events related to the provision of rTMS treatment. A trend toward significant (P = .066) neurobehavioral gains was temporally related to provision of rTMS. Left-sided brain stem auditory EP wave V latencies and waves I to V interpeak latencies improved along with neurobehavioral gains during provision of rTMS, suggesting that improved neural conduction in the pathway mediated the neurobehavioral improvements.

CONCLUSIONS

Repetitive TMS merits further investigation as a safe therapeutic intervention to alter neural activity, to modulate neural activity, and/or to facilitate recovery in persons with disordered consciousness subsequent to severe TBI.

Transcranial magnetic stimulation: a possible treatment for TBI

The purpose of this article is to outline the principles of transcranial magnetic stimulation (TMS), to summarize the existing use of TMS as a prognostic indicator and as a therapeutic device in clinical populations, and to highlight the potential of repetitive TMS (rTMS) as an intervention for traumatic brain injury. TMS is a painless method to stimulate the human brain. Repeated applications of TMS can influence brain plasticity and cortical reorganization through stimulation-induced alterations in neuronal excitability. Existing evidence has demonstrated positive outcomes in people with motor disorders and psychiatric conditions who have received rTMS as a therapeutic intervention. These findings suggest that rTMS may be a promising treatment for people with traumatic brain injury.

A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of Disorders of Consciousness Scale

This is longitudinal validation study describes the psychometric properties of the Disorders of Consciousness Scale (DOCS). This is Part I of a two-part series. Part II illustrates and describes the clinical and scientific implementation of the DOCS measure. The study was conducted at one intensive care unit, two acute rehabilitation hospitals, and one long-term acute chronic care hospital. Participants were unconscious after severe brain injury (BI). We conducted interrater reliability analyses using ratings from interdisciplinary pairs. Results indicated a higher-than-expected level of agreement and no significant difference between any pairs ( chi-square = 8(5df), p = 0.15) (df = degrees of freedom). Examinations of ratings by discipline groups indicated that the DOCS is impacted minimally by discipline. Validity analyses demonstrate that 23 of 34 test stimuli remain stable over time with no floor or ceiling effect. DOCS measures obtained within 94 days of injury predicted recovery of consciousness up to 1 year after injury (c-indices of 0.70 and 0.86). Positive (0.71) and negative (0.68) predictive values indicate that the DOCS predicts recovery and lack of recovery. Twenty-three of the DOCS test stimuli produce a reliable, valid, and stable measure of neurobehavioral recovery after severe BI that predicts recovery and lack of recovery of consciousness 1 year after injury.

A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation

This is a longitudinal validation study that is Part II of a two-part series. Part I focuses on the methods used to construct the neurobehavioral measure derived from the Disorders of Consciousness Scale (DOCS) as well as the evidence of reliability and validity. Part II illustrates, through a series of selected case reports, the clinical use of repeated DOCS measures to enhance and complement medical rehabilitation management. The use of repeated DOCS measures in scientific investigations of mechanisms of injury is also described. Participants included patients at rehabilitation hospitals who were 18 years of age and older and unconscious after severe brain injury. Medical decision making regarding short-term effects of pharmacological intervention was augmented and improved through the examination of individual neurobehavioral recovery patterns. We identified medications to treat secondary medical complications and successfully determined effective dosage, presumably improving prognosis for recovery. We facilitated and enhanced development and refinement of individualized rehabilitation programs. Two investigations of treatment effectiveness during coma recovery and examination of the relationship between behavioral changes and neural adaptation are also described. By systematically tracking and mapping individual patterns of neurobehavioral recovery, we show that medical and rehabilitation management after coma can be enhanced. In addition, we also show that by examining the relationship between the DOCS neurobehavioral measure with mechanistic indicators of neurological recovery such as functional magnetic resonance imaging, scientific investigations of treatment and rehabilitation effectiveness can be enhanced.

Employment issues and assistive technology use for persons with spinal cord injury

In this study, we examined associations between assistive technology (AT) cost, underwriting, ownership, use, employment, and employer accommodations for two groups (civilian and veteran) of working age adults (18-64 yr) with spinal cord injury or dysfunction (SCI/D). The project included the development of a survey instrument, and initial findings indicate that AT is important for the employment success of individuals with SCI/D. The majority of the AT devices owned by the respondents were characterized as important to work, and these devices were 3.5 times more expensive. The mean cost of assistive devices was 68% to 124% greater for persons who were self-employed compared with persons employed by others. Education was related to employment status for both groups. In addition, satisfaction with assistive devices was very high regardless of employment status or history.

Unresolved legal and ethical issues in research of adults with severe traumatic brain injury: Analysis of an ongoing protocol

This paper synthesizes federal and state laws and bioethics literature with observations from an ongoing research protocol to identify, define, and clarify the unresolved legal and ethical issues regarding research involving adults with traumatic brain injury (TBI). Solutions that protect rights and minimize unnecessary impediments to valuable clinical and scientific inquiry are also illustrated using the same protocol. Research was performed at intensive care, inpatient rehabilitation, and long-term acute chronic hospitals. Our research protocol identified five areas of law impacting adults with TBI: advanced directives, healthcare surrogacy acts, probate acts, power of attorney acts, and the Health Insurance Portability and Accountability Act. The published bioethics literature and responses from local human subject institutional review boards (IRBs) suggest that some of the unresolved ethical issues in research include defining vulnerability, defining informed voluntary consent, determining competency and/or decision-making capacity, using caregivers as subjects, and conducting multisite cooperative studies. Collaboration with IRB members and administrators as well as legal and research ethic scholars developed procedures that protect rights while avoiding unnecessary impediments to research. Investigations of persons with TBI and other cognitive impairments are governed by complicated and inconsistent regulations within the Common Rule and federal and state statues. A need for clear and consistent regulatory guidance regarding multisite studies of TBI persists. In lieu of regulatory guidance, carefully researched solutions for critical peer review are needed to guide future multisite investigations of TBI.