CONNECT: A pragmatic clinical trial testing a remotely provided linkage to service coordination after hospitalization for TBI.

OBJECTIVE: To test whether a complex behavioral intervention delivered remotely to connect individuals to clinical resources after hospitalization for TBI improved their quality of life. DESIGN/METHODS: Community-based randomized pragmatic clinical trial. Main measures TBI-QOL, Activity Measure for Post-Acute Care (AM-PAC), Clinical Satisfaction and Competency Rating Scale. RESULTS: 332 individuals ≥18 years-old hospitalized for TBI in four upper Midwest states were randomized to Remote (n = 166) and Usual Care (n = 166) groups. The groups were equivalent and representative of their state population's racial and ethnic composition, age, and proportion living in rural communities. There were no significant differences within or between experimental groups over the study period in TBI-QOL t-scores. There was a significant improvement in AM-PAC Daily Activities within the Remote group and a significant between-group improvement in clinical satisfaction for the Remote group. CONCLUSION: Enrolling a representative, regional community-based sample of individuals with TBI can be successful, and delivering a customized complex behavioral intervention remotely is feasible. The overall lack of intervention effectiveness was likely due to enrolling individuals without pre-identified clinical needs, initiating intervention after the immediate post-acute phase when needs are often highest, inability to provide direct clinical care remotely, and potential lack of outcome measure responsiveness in our sample.

A randomized practical behavioural trial of curriculum-based advocacy training for individuals with traumatic brain injury and their families.

PRIMARY OBJECTIVE: To test whether a curriculum-based advocacy training programme improves advocacy behaviour when compared to a matched group engaged in self-directed advocacy activities. RESEARCH DESIGN: Community-based randomized practical behavioural trial. METHODS AND PROCEDURES: Adults with moderate-severe TBI 1 or more years post-injury and their family members were recruited in Minnesota (4 years), Iowa and Wisconsin (each 3 years) and randomized into a curriculum-based or self-directed advocacy training group. Both groups met on the same day, at separate locations in the same city, once per month for 4 consecutive months. MAIN OUTCOMES AND RESULTS: Pre-post written and video testimony were rated using the Advocacy Behaviour Rating Scale (ABRS). Mean ABRS scores increased after intervention in both groups (curriculum n = 129, self-directed n = 128), but there was no significant difference in this increase between groups. When groups were combined, a significant pre-post improvement in mean ABRS scores was observed. CONCLUSIONS: Curriculum-based advocacy training was not superior to a self-directed approach in improving ABRS scores. A significant improvement in expression of an advocacy message was observed when intervention groups were combined. These findings suggest that bringing together like-minded motivated individuals is more important than programme structure or content in changing advocacy behaviour.

Ice Hockey Summit II: zero tolerance for head hits and fighting.

OBJECTIVE: To present currently known basic science and on-ice influences of sport-related concussion (SRC) in hockey, building on the Ice Hockey Summit I action plan (2011) to reduce SRC. METHODS: The prior summit proceedings included an action plan intended to reduce SRC. As such, the proceedings from Summit I served as a point of departure, for the science and discussion held during Summit II (Mayo Clinic, Rochester MN, October 2013). Summit II focused on (1) Basic Science of Concussions in Ice Hockey: Taking Science Forward; (2) Acute and Chronic Concussion Care: Making a Difference; (3) Preventing Concussions via Behavior, Rules, Education and Measuring Effectiveness; (4) Updates in Equipment: their Relationship to Industry Standards; and (5) Policies and Plans at State, National and Federal Levels to reduce SRC. Action strategies derived from the presentations and discussion described in these sectors were subsequently voted on for purposes of prioritization. The following proceedings include knowledge and research shared by invited faculty, many of whom are health care providers and clinical investigators. RESULTS: The Summit II evidence-based action plan emphasizes the rapidly evolving scientific content of hockey SRC. It includes the most highly prioritized strategies voted on for implementation to decrease concussion. CONCLUSIONS: The highest priority action items identified from the Summit includes the following: (1) eliminate head hits from all levels of ice hockey, (2) change body-checking policies, and (3) eliminate fighting in all amateur and professional hockey.

Ice hockey summit II: zero tolerance for head hits and fighting.

OBJECTIVE: To present currently known basic science and on-ice influences of sport related concussion (SRC) in hockey, building upon the Ice Hockey Summit I action plan (2011) to reduce SRC. METHODS: The prior summit proceedings included an action plan intended to reduce SRC. As such, the proceedings from Summit I served as a point of departure, for the science and discussion held during Summit II (Mayo Clinic, Rochester MN, October, 2013). Summit II focused on Basic Science of Concussions in Ice Hockey: Taking Science Forward; (2) Acute and Chronic Concussion Care: Making a Difference; (3) Preventing Concussions via Behavior, Rules, Education and Measuring Effectiveness; (4) Updates in Equipment: their Relationship to Industry Standards and (5) Policies and Plans at State, National and Federal Levels to reduce SRC. Action strategies derived from the presentations and discussion described in these sectors were subsequently voted on for purposes of prioritization. The following proceedings include the knowledge and research shared by invited faculty, many of whom are health care providers and clinical investigators. RESULTS: The Summit II evidence based action plan emphasizes the rapidly evolving scientific content of hockey SRC. It includes the most highly prioritized strategies voted on for implementation to decrease concussion. CONCLUSIONS: The highest priority action items identified from the Summit include: 1) eliminate head hits from all levels of ice hockey, 2) change body checking policies, and 3) eliminate fighting in all amateur and professional hockey.

Ice Hockey Summit II: zero tolerance for head hits and fighting.

This study aimed to present currently known basic science and on-ice influences of sport-related concussion (SRC) in hockey, building upon the Ice Hockey Summit I action plan (2011) to reduce SRC. The prior summit proceedings included an action plan intended to reduce SRC. As such, the proceedings from Summit I served as a point of departure for the science and discussion held during Summit II (Mayo Clinic, Rochester, MN, October 2013). Summit II focused on (1) Basic Science of Concussions in Ice Hockey: Taking Science Forward, (2) Acute and Chronic Concussion Care: Making a Difference, (3) Preventing Concussions via Behavior, Rules, Education, and Measuring Effectiveness, (4) Updates in Equipment: Their Relationship to Industry Standards, and (5) Policies and Plans at State, National, and Federal Levels To Reduce SRC. Action strategies derived from the presentations and discussion described in these sectors were voted on subsequently for purposes of prioritization. The following proceedings include the knowledge and research shared by invited faculty, many of whom are health care providers and clinical investigators. The Summit II evidence-based action plan emphasizes the rapidly evolving scientific content of hockey SRC. It includes the most highly prioritized strategies voted on for implementation to decrease concussion. The highest-priority action items identified from the Summit include the following: (1) eliminate head hits from all levels of ice hockey, (2) change body checking policies, and (3) eliminate fighting in all amateur and professional hockey.

A survey of very-long-term outcomes after traumatic brain injury among members of a population-based incident cohort.

To assess quality of life and barriers to participation in vocational and community life for persons with traumatic brain injury (TBI) over the very-long term, a population-based cohort was identified in Olmsted County, Minnesota; 1623 individuals were identified as having experienced a confirmed TBI while a resident of Olmsted County, Minnesota, during the period from 1935-2000. A survey was sent to eligible individuals that included elements of standardized instruments addressing health status and disability, and questions that assessed issues important to successful social reintegration after TBI. Of 1623 eligible participants sent surveys, 605 responded (37% response rate). Thirty-nine percent of respondents were female and 79% had mild injuries. Mean age at injury was 30.8 years, and mean years since injury was 28.8. Overall, respondents reported living in the community; the majority were married and had achieved education beyond high school. Problems with memory, thinking, and physical and emotional health were most often reported. Respondents reported low levels of depression and anxiety, and high levels of satisfaction with life. Seventy-three percent of respondents reported no problems that they attributed to their TBI. Increasing injury severity was associated with a significant risk of reporting injury-related problems at survey completion. Respondents with a longer time since injury were less likely to report any TBI-related problems. These results indicate that self-reported outcomes and adaptation to impairment-related limitations improve as the time since injury increases. These findings highlight the importance of providing coordinated medical rehabilitation and community-based support services to promote positive outcomes over the life span after TBI.

A preliminary model for posttraumatic brain injury depression.

OBJECTIVE: To develop, based on previous research, and evaluate a model for depression after traumatic brain injury (TBI). DESIGN: Cross-sectional structural equation modeling (SEM) of data from consecutively recruited patients. SETTING: Acute hospital and inpatient rehabilitation units. PARTICIPANTS: Adult patients (N=158) after hospital admission for moderate to severe TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: External appraisal of ability in participants was measured by the Mayo-Portland Adaptability Inventory (MPAI-4) Ability Index completed by a TBI clinical nurse specialist. Patient self-appraisal of post-TBI ability and depression were measured by the Awareness Questionnaire and Beck Depression Inventory-II. Functional outcome 1 year after injury was assessed with the MPAI-4 Participation Index. RESULTS: Successive SEM resulted in a parsimonious model with excellent fit. Consistent with prior research, a moderately strong association between self-appraisal of post-TBI ability and depression was found. Injury severity, as measured by the duration of posttraumatic amnesia (PTA), was not significantly associated with post-TBI depression. The 1-year functional outcome was associated with depression and TBI severity. CONCLUSIONS: The strong association between self-appraisal of post-TBI ability and depression is consistent with the cognitive-behavioral model of depression and recommends consideration and further study of cognitive-behavioral therapy for post-TBI depression. The lack of association between TBI severity and depression may represent the indirect and proxy nature of current measures of TBI severity such as PTA. Emerging neuroimaging techniques (eg, diffusion tensor imaging, magnetic resonance imaging spectroscopy) may provide the more direct measures of disruption of brain function after TBI that are needed to advance this line of research.

Two new measures for assessing advocacy activities and perceived control after acquired brain injury.

PURPOSE: To develop and evaluate the psychometric properties of measures of advocacy activity and perceived control specific to those affected by acquired brain injury (ABI). METHOD: Questionnaires, including initial forms of the Advocacy Activities Scale (AAS) and Perceived Control Scale for brain injury (PCS-BI), Craig Hospital Inventory of Environmental Factors, Satisfaction with Life Scale and SF-12, were mailed through the State Brain Injury Associations in three states in the Upper Midwestern U.S. Through multiple mailings, 322 (21.4%) complete response sets of 1550 possible were obtained; 196 from individuals with ABI, 99 from significant others (SOs), and 27 with no indication of whether the respondent was a person with BI or SO. The AAS and PCS-BI were analyzed and refined using a two parameter item response theory model. Concurrent validity was examined through simple correlations and principal components analyses of all measures. RESULTS: After modification based on IRT analyses, the AAS showed satisfactory internal consistency (Person reliability = 0.77; item reliability = 0.97) as did the PCS-BI (Person reliability = 0.78; item reliability = 0.99). Although more complex than the predicted, relationships with other measures supported the concurrent validity of the AAS and PCS-BI. CONCLUSIONS: The AAS and PCS-BI are reliable and valid measures of advocacy activity and an associated sense of perceived control among those affected by ABI for use in survey research and assessing the effectiveness of interventions to increase advocacy activity.

Injury severity and disability in the selection of next level of care following acute medical treatment for traumatic brain injury.

PRIMARY OBJECTIVE: To evaluate the association of demographic factors, post-traumatic amnesia (PTA) and a standardized measure of ability limitations with clinical decisions for Next Level of Care following acute hospital treatment for moderate-severe traumatic brain injury (TBI). RESEARCH DESIGN: A TBI Clinical Nurse specialist recorded PTA for 212 individuals and rated 159 on the Ability and Adjustment Indices of the Mayo-Portland Adaptability Inventory (MPAI-4) for comparison with clinical decisions. MAIN OUTCOMES AND RESULTS: Multivariate logistic regression analyses revealed that independent ratings on the MPAI-4 Ability Index and PTA were associated with the clinical decision to admit to Inpatient Rehabilitation vs discharge to Home in 92.7% of the sample; ratings on the Ability Index alone were associated with this decision in 92.2% of cases. Age over 65 was the only variable associated with discharge to a Skilled Nursing Facility, correctly predicting this decision in 64% of cases. CONCLUSIONS: Use of a standardized measure of ability limitations appears feasible to provide supportive documentation and potentially improve the consistency of decision-making in recommending Inpatient Rehabilitation vs discharge to Home. Although age is a significant factor in the decision to discharge to a Skilled Nursing Facility, this decision appears complex and merits further study.

Self-assessment of impairment, impaired self-awareness, and depression after traumatic brain injury.

OBJECTIVE: To identify patient features associated with early and late depression after traumatic brain injury (TBI). PARTICIPANTS: 3 clinical trauma groups (mild TBI, moderate-severe TBI, orthopedic injury) and their significant others. MEASURES: Preinjury: age, education, substance abuse, and psychiatric history; Injury severity: classification using Glasgow Coma Scale and cranial CT scan, posttraumatic amnesia; Early impairment: Neurobehavioral Functioning Inventory (NFI), Impaired Self-Awareness (ISA); Social and family support: Multidimensional Scale of Perceived Social Support, Family Assessment Device; Depression: NFI Depression Scale. METHOD: Regression analyses of predictor variables on early and late measures of depression. RESULTS: Depression rates did not differ among the 3 trauma groups. Preinjury level of education, previous psychiatric history, and perceived level of social support explained a small portion of the variance in depressive symptoms. Patients' self-assessment of their impairment at discharge was most strongly correlated with both early and late depression. ISA was associated with reduced self-report of depressive symptoms. However, when those with ISA were excluded from the analysis, self-assessment of impairment remained strongly associated with depression. CONCLUSIONS: Patients' self-assessment of impairment is strongly associated with early and late depression. Presence and severity of TBI does not appear to play a direct role in depression but does appear related to ISA, which serves as a barrier to the development of depression. Focusing on impairment appears to be a cardinal feature of depression in both patients with TBI and an orthopedic trauma group.

Predicting family functioning after TBI: impact of neurobehavioral factors.

OBJECTIVE: To identify risk factors for poor family functioning and neurobehavioral problems after traumatic brain injury (TBI) or orthopedic injuries (OI). DESIGN: Longitudinal analyses of data from an inception cohort. PARTICIPANTS: Seventy-five patients with moderate/severe TBI, 47 patients with mild TBI, and 44 patients with OI at discharge; and 49 patients with moderate/severe TBI, 24 patients with mild TBI, and 33 patients with OI at 1-year follow-up. OUTCOME MEASURES: Measures of family functioning (Family Assessment Device) and Neurobehavioral Functioning Index at hospital discharge and 1-year follow-up. RESULTS: At discharge, patients with moderate/severe TBI had more symptoms of depression, memory/attention problems, and motor impairments than patients with OI and greater communication difficulties than patients with OI or mild TBI. At follow-up, patients with moderate/severe TBI continued to have more problems in memory/attention, depression, and communication. Approximately one third of each group had unhealthy family functioning at each assessment period. Few patients reported both impaired family functioning and clinical depression. Distressed family functioning correlated strongly with increased rates of neurobehavioral symptoms. Family dysfunction at follow-up was best predicted by family dysfunction at discharge and depression or memory/attention deficits at follow-up. CONCLUSIONS: After TBI, patients at the greatest risk for distress at follow-up were those with family dysfunction at discharge and continued neurobehavioral problems. High-risk families need to be identified so that necessary referrals and/or treatment can be offered.

Replicated positive results for the VCC model of vocational intervention after ABI within the social model of disability.

PRIMARY OBJECTIVE: Replicated evaluation of the Vocational Case Co-ordinator (VCC) Model for vocational rehabilitation after acquired brain injury (ABI). RESEARCH DESIGN: Referral cohort studied within the social model of disability. METHODS AND PROCEDURES: One hundred and thirty-eight participants with ABI were assisted by a VCC to develop self-directed vocational plans and networks of medical centre and community services. Early intervention, work trials, temporary or long-term supported employment and employer education are fundamental features of the VCC Model. MAIN OUTCOMES AND RESULTS: One year after initial placement 80% of participants remained in community-based employment, 56% of the total sample with no support. Better outcomes were associated with earlier intervention but not with initial injury severity. CONCLUSIONS: Results replicate original findings of the effectiveness of the VCC Model of vocational rehabilitation after ABI with a different VCC. Implications for social change within the social model of disability are discussed.

Outcome after traumatic brain injury: effects of aging on recovery.

OBJECTIVE: To identify differences in outcome after traumatic brain injury (TBI) compared with orthopedic injuries as a function of age. DESIGN: Longitudinal data analyses from an inception cohort. SETTING: Outpatient rehabilitation program. PARTICIPANTS: Eighty-two orthopedic injury patients and 195 TBI patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent living, employment, and level of functioning 1 to 2 years after injury. RESULTS: Older patients and those with TBI were more likely to have increased dependence postinjury. Older TBI patients were more likely to have changes in employment status compared with orthopedic injury patients younger or TBI. The Mayo-Portland Adaptability Inventory and Disability Rating Scale were moderately predictive of level of functioning, return to employment, and independent living status 1 to 2 years postinjury. Injury severity was only mildly predictive of outcome. CONCLUSIONS: The effect of age on outcome affects recovery from neurologic injuries and, to a lesser extent, orthopedic injuries. Outcome after TBI is best predicted by patients' age and estimates of level of function at discharge. Findings suggest that older patients and those with TBI have a greater likelihood of becoming physically and financially dependent on others. Rehabilitation efforts should focus on maximizing levels of independence to limit financial and emotional costs to patients and their families.

An assessment of gait and balance deficits after traumatic brain injury.

OBJECTIVE: To assess the sensations of instability that many patients report after traumatic brain injury (TBI). DESIGN: A controlled study. SETTING: A motion analysis and vestibular and balance laboratory. PARTICIPANTS: Twenty subjects, 10 with TBI and complaints of instability, and 10 without TBI. INTERVENTIONS: Balance and gait analysis. MAIN OUTCOME MEASURES: Dizziness Handicap Inventory (DHI), caloric irrigation, optokinetic testing, Dix-Hallpike Test, posturography, and center of mass (COM) movement. RESULTS: Subjects were well matched in terms of age, height, weight, and gender. DHI scores of those with and without TBI differed significantly (32.2+/-23.0 vs 0.2+/-0.63, P<.001). Caloric and optokinetic circularvection testing were abnormal only in subjects with TBI (8/10 and 4/10, respectively). Benign paroxysmal positioning vertigo was present in only 3 subjects with TBI, and this either resolved spontaneously (n=1) or was successfully treated (n=2). Composite posturography scores of those with and without TBI differed significantly (69.6+/-35.8 vs 79.5+/-40.5, P=.02). Gait parameters also differed significantly between the groups (P=.05), with the subjects with TBI having lower anterior and posterior and higher medial and lateral COM displacements and velocities. CONCLUSIONS: Patients' complaints of instability after TBI may have objective correlates and may be rectifiable. Balance and gait testing in these patients is warranted.

Preinjury emotional and family functioning in caregivers of persons with traumatic brain injury.

OBJECTIVE: To characterize the preinjury family functioning, emotional distress, and social support of caregivers of persons with traumatic brain injury (TBI). DESIGN: Inception cohort. SETTING: Three Traumatic Brain Injury Model Systems centers' inpatient rehabilitation facilities. PARTICIPANTS: One hundred ninety-one caregivers, primarily white and female, of persons with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Brief Symptom Inventory, Family Assessment Device, Multidimensional Scale of Perceived Social Support, and history of medical and psychiatric illness. RESULTS: Thirty-seven percent of caregivers indicated symptoms of emotional distress consistent with psychiatric diagnoses for the month before injury, whereas 27% reported a history of psychiatric or psychologic treatment at some point in the past. Between 25% and 33% of caregivers reported unhealthy family functioning in 1 or more areas for the month before injury. Persons with an annual income less than US dollars 10,000 reported less healthy preinjury family functioning. Caregivers reported good satisfaction with preinjury social support, and very few caregivers reported a history of substance abuse. CONCLUSION: A substantial proportion of caregivers reported emotional distress and/or unhealthy family functioning before injury. Such difficulties may make them more vulnerable to the stress associated with injury and result in greater coping difficulties.