Associations between self-generated strategy use and MET-Home performance in adults with stroke.

Self-generated strategy use has substantial potential for improving community living outcomes in adults with impaired executive function after stroke. However, little is known about how self-generated strategies support task performance in people with post-stroke executive function impairments living in the community. We explored strategy use among home-dwelling persons with stroke and neurologically-healthy control participants during the Multiple Errands Test-Home Version (MET-Home), a context-specific assessment with evidence of ecological validity designed to examine how post-stroke executive dysfunction manifests during task performance in the home environment. For persons with stroke, significant associations were identified between planning and tasks accurately completed on the MET-Home. Significant associations were also identified among the control participants for self-monitoring, multitasking, and "using the environment" strategies. These associations are related to enhanced MET-Home performance on sub-scores for levels of accuracy, passes, and total time. Rehabilitation interventions that focus on reinforcing self-generated strategy use may support community living outcomes in persons with post-stroke executive function impairments, but this area needs additional investigation.

In-home contextual reality: a qualitative analysis using the Multiple Errands Test Home Version (MET-Home).

Adults with stroke frequently experience executive dysfunction. Despite the range of assessments that examine the effects of executive dysfunction on daily tasks, there remains a paucity of literature that examines the influence of the environment on performance in the community. The MET-Home is an ecologically valid assessment for examining post-stroke executive dysfunction in the home environment. This qualitative study explores the relationship between the environment and MET-Home performance among home-dwelling adults with stroke and matched controls. Using a descriptive qualitative approach, we analysed video, interview, and observation notes from a MET-Home validation study. An overarching theme of interplay between everyday task performance and the home environment produced further themes: naturalistically emerging supports and barriers and environment as strategy. Within naturalistically emerging supports and barriers, five contextual sub-themes were discovered: physical environment, social environment, temporal context, virtual context, and personal context. Within environment as strategy, we identified four sub-themes: reducing distractions, using everyday technologies, planning in context, and seeking social support. These findings extend the conceptualisation of how we evaluate executive dysfunction in the context of the community to also consider the inherent influence of the environment.

Ecologically relevant outcome measure for post-inpatient rehabilitation.

BACKGROUND: Transfer of skills learned within the clinic environment to patients' home or community is important in post-inpatient brain injury rehabilitation (PBIR). Outcome measures used in PBIR assess level of independence during functional tasks; however, available functional instruments do not quantitate the environment in which the behaviors occur. OBJECTIVE: To examine the reliability and validity of an instrument used to assess patients' functional abilities while quantifying the amount of structure and distractions in the environment. METHODS: 2501 patients who sustained a traumatic brain injury (TBI) or cerebrovascular accident (CVA) and participated in a multidisciplinary PBIR program between 2006 and 2014 were identified retrospectively for this study. The PERPOS and MPAI-4 were used to assess functional abilities at admission and at discharge. Construct validity was assessed using a bivariate Spearman rho analysis A subsample of 56 consecutive admissions during 2014 were examined to determine inter-rater reliability. Intra-class correlation coefficient (ICC) and Kappa coefficients assessed inter-rater agreement of the total PERPOS and PERPOS subscales respectively. RESULTS: The PERPOS and MPAI-4 demonstrated a strong negative association among both TBI and CVA patients. Kappa scores for the three PERPOS scales each demonstrated good to excellent inter-rater agreement. The ICC for overall PERPOS scores fell in the good agreement range. CONCLUSION: The PERPOS can be used reliably in PBIR to quantify patients' functional abilities within the context of environmental demands.

fNIRS-based investigation of the Stroop task after TBI.

To evaluate neural changes during a Stroop task among individuals with TBI using functional near-infrared spectroscopy (fNIRS). Thirteen healthy controls and 14 patients with moderate to severe TBI were included in this study. Oxygenated hemoglobin (HbO) was recorded every tenth of a second using a 52-channel fNIRS unit. Data were acquired using a block design during a Stroop task (i.e., Condition A = Dot Color Naming, Condition B = Incongruent Condition). Visual stimuli were presented on a computer monitor. Behaviorally, response accuracy was similar between groups for condition A, but the TBI group made more errors than the control group during condition B. During condition A, the patient group demonstrated significant increases in HbO within bilateral frontal regions compared to controls (p < 0.01). When examining the Stroop interference effect (B-A), controls showed increased HbO in bilateral frontal lobes and left inferior parietal region suggesting increased neural response to increased cognitive demand, whereas no differences were detected among the TBI group (p < 0.05). No between group differences in latency of HbO response was observed during either condition. While the TBI group performed as accurately as controls on the simpler dot color naming condition of the Stroop task, neural activity was greater within the frontal lobes during this relatively simple task among the TBI group suggesting neural inefficiency. Furthermore, the spatial distribution of neural activity related to the interference effect was not different among patients, suggesting the neural demand for the simpler task was comparable to that of the more cognitive demanding task among the TBI sample. The results suggest that fNIRS can identify frontal lobe inefficiency in TBI commonly observed with fMRI.

Cytotoxic and vasogenic cerebral oedema in traumatic brain injury: assessment with FLAIR and DWI imaging.

PRIMARY OBJECTIVE: Cerebral oedema is a common complication of traumatic brain injury (TBI). The use of Fluid-Attenuated Inversion Recovery (FLAIR) imaging in combination with Diffusion Weighted Imaging (DWI) has the potential to distinguish between cytotoxic and vasogenic oedema. This study hypothesized a significant relationship between cytotoxic lesion volume and outcome. RESEARCH DESIGN: This observational study reports on a convenience sample where MRI was obtained for clinical purposes. METHODS AND PROCEDURES: Clinical post-TBI FLAIR and DWI images were analysed. For this study, lesions were defined as primarily cytotoxic oedema if the ratio of FLAIR to DWI lesion volume was comparable, defined as a ratio <2. If the ratio of FLAIR to DWI lesion volume was ≥2, oedema was considered predominantly of vasogenic origin. MAIN OUTCOMES AND RESULTS: The sample consisted primarily of males with TBIs whose injury severity ranged from complicated mild to severe. Analysis revealed that both oedema types are common after TBI and both are associated with functional deficits 6 months after injury. CONCLUSIONS: Acute MRI may be useful to assess pathology at the tissue after traumatic brain injury. Clinical trials targeting cytotoxic and vasogenic mechanisms of oedema formation may benefit from using DWI and FLAIR MRI as a means to differentiate the predominant oedema type after TBI.

Longitudinal white matter changes after traumatic axonal injury.

Diffusion tensor imaging (DTI) has been useful in showing compromise after traumatic axonal injury (TAI) at the chronic stage; however, white matter (WM) compromise from acute stage of TAI to chronic stage is not yet well understood. This study aims to examine changes in WM integrity following TAI by obtaining DTI, on average, 1 d post injury and again approximately seven months post-injury. Sixteen patients with complicated mild to severe brain injuries consistent with TAI were recruited in the intensive care unit of a Level I trauma center. Thirteen of these patients were studied longitudinally over the course of the first seven months post-injury. The first scan occurred, on average, 1 d after injury and the second an average of seven months post-injury. Ten healthy individuals, similar to the cohort of patients, were recruited as controls. Whole brain WM and voxel-based analyses of DTI data were conducted. DTI metrics of interest included: fractional anisotropy (FA), mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD). tract-based spatial statistics were used to examine DTI metrics spatially. Acutely, AD and RD increased and RD positively correlated with injury severity. Longitudinal analysis showed reduction in FA and AD (p<0.01), but no change in RD. Possible explanations for the microstructural changes observed over time are discussed.

Three approaches to investigating functional compromise to the default mode network after traumatic axonal injury.

The default mode network (DMN) is a reliably elicited functional neural network with potential clinical implications. Its discriminant and prognostic utility following traumatic axonal injury (TAI) have not been previously investigated. The present study used three approaches to analyze DMN functional connectedness, including a whole-brain analysis [A1], network-specific analysis [A2], and between-node (edge) analysis [A3]. The purpose was to identify the utility of each method in distinguishing between healthy and brain-injured individuals, and determine whether observed differences have clinical significance. Resting-state fMRI was acquired from 25 patients with TAI and 17 healthy controls. Patients were scanned 6-11 months post-injury, and functional and neurocognitive outcomes were assessed the same day. Using all three approaches, TAI subjects revealed significantly weaker functional connectivity (FC) than controls, and binary logistic regressions demonstrated all three approaches have discriminant value. Clinical outcomes were not correlated with FC using any approach. Results suggest that compromise to the functional connectedness of the DMN after TAI can be identified using resting-state FC; however, the degree of functional compromise to this network, as measured in this study, may not have clinical implications in chronic TAI.

Evaluating the effectiveness of reasoning training in military and civilian chronic traumatic brain injury patients: study protocol.

BACKGROUND: Individuals who sustain traumatic brain injuries (TBIs) often continue to experience significant impairment of cognitive functions mediated by the prefrontal cortex well into chronic stages of recovery. Traditional brain training programs that focus on improving specific skills fall short of addressing integrative functions that draw upon multiple higher-order processes critical for social and vocational integration. In the current study, we compare the effects of two short-term, intensive, group-based cognitive rehabilitation programs for individuals with chronic TBI. One program emphasizes learning about brain functions and influences on cognition, while the other program adopts a top-down approach to improve abstract reasoning abilities that are largely reliant on the prefrontal cortex. These treatment programs are evaluated in civilian and military veteran TBI populations. METHODS/DESIGN: One hundred individuals are being enrolled in this double-blinded clinical trial (all measures and data analyses will be conducted by blinded raters and analysts). Each individual is randomly assigned to one of two treatment conditions, with each condition run in groups of five to seven individuals. The primary anticipated outcomes are improvement in abstract reasoning and everyday life functioning, measured through behavioral tasks and questionnaires, and attention modulation, as measured by functional neuroimaging. Secondary expected outcomes include improvements in the cognitive processes of working memory, attention, and inhibitory control. DISCUSSION: Results of this trial will determine whether cognitive rehabilitation aimed at teaching TBI-relevant information about the brain and cognition versus training in TBI-affected thinking abilities (e.g., memory, attention, and executive functioning) can improve outcomes in chronic military and civilian TBI patient populations. It should shed light on the nature of improvements and the characteristics of patients most likely to benefit. This trial will also provide information about the sustainability of treatment-related improvements 3 months post-training. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01552473.

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.

Brain morphometry changes and depressive symptoms after traumatic brain injury.

Traumatic brain injury (TBI) is associated with an increased risk of depressive symptoms. Recent imaging studies on spontaneous depression have implicated several brain structures; however, few studies have done the same for post-TBI depression. We report on a pilot observational study correlating atrophy of brain regions of interest in subjects after TBI with depressive symptoms measured by the Beck Depression Inventory-II. Regional brain volumes were calculated on both acute and 6-month MRI using an automated segmentation algorithm (FreeSurfer). Percent volume changes in brain regions were correlated with BDI-II scores using Spearman's rank order correlation coefficient. Correction for multiple comparisons was performed using the false discovery rate (FDR). Three regions of interest (left rostral anterior cingulate and bilateral orbitofrontal cortex) were found to be significantly correlated with depressive symptoms (FDR 0.05). With FDR 0.1, six regions were significantly correlated. The use of volumetric analysis of brain regions of interest to study post-TBI depression is worthy of further study. Regions associated with depressive symptoms in this pilot study were similar to those implicated in study of spontaneous depression.

Deficits in functional connectivity of hippocampal and frontal lobe circuits after traumatic axonal injury.

OBJECTIVE: To examine the functional connectivity of hippocampal and selected frontal lobe circuits in patients with traumatic axonal injury (TAI). DESIGN: Observational study. SETTING: An inpatient traumatic brain injury unit. Imaging and neurocognitive assessments were conducted in an outpatient research facility. PARTICIPANTS: Twenty-five consecutive patients with brain injuries consistent with TAI and acute subcortical white matter abnormalities were studied as well as 16 healthy volunteers of similar age and sex. INTERVENTIONS: Echo-planar and high-resolution T1-weighted images were acquired using 3-T scanners. Regions of interest (ROI) were drawn bilaterally for the hippocampus, anterior cingulate cortex (ACC), and dorsolateral prefrontal cortex and were used to extract time series data. Blood oxygenation level-dependent data from each ROI were used as reference functions for correlating with all other brain voxels. Interhemispheric functional connectivity was assessed for each participant by correlating homologous regions using a Pearson correlation coefficient. Patient functional and neurocognitive outcomes were assessed approximately 6 months after injury. MAIN OUTCOME MEASURES: Interhemispheric functional connectivity, spatial patterns of functional connectivity, and associations of connectivity measures with functional and neurocognitive outcomes. RESULTS: Patients showed significantly lower interhemispheric functional connectivity for the hippocampus and ACC. Controls demonstrated stronger and more focused functional connectivity for the hippocampi and ACC, and a more focused recruitment of the default mode network for the dorsolateral prefrontal cortex ROI. The interhemispheric functional connectivity for the hippocampus was correlated with delayed recall of verbal information. CONCLUSIONS: Traumatic axonal injury may affect interhemispheric neural activity, as patients with TAI show disrupted interhemispheric functional connectivity. More careful investigation of interhemispheric connectivity is warranted, as it demonstrated a modest association with outcome in chronic TBI.

Diffusion tensor imaging biomarkers for traumatic axonal injury: analysis of three analytic methods.

Traumatic axonal injury (TAI) is a common mechanism of traumatic brain injury not readily identified using conventional neuroimaging modalities. Novel imaging modalities such as diffusion tensor imaging (DTI) can detect microstructural compromise in white matter (WM) in various clinical populations including TAI. DTI-derived data can be analyzed using global methods (i.e., WM histogram or voxel-based approaches) or a regional approach (i.e., tractography). While each of these methods produce qualitatively comparable results, it is not clear which is most useful in clinical research and ultimately in clinical practice. This study compared three methods of analyzing DTI-derived data with regard to detection of WM injury and their association with clinical outcomes. Thirty patients with TAI and 19 demographically similar normal controls were scanned using a 3 Tesla magnet. Patients were scanned approximately eight months postinjury, and underwent an outcomes assessment at that time. Histogram analysis of fractional anisotropy (FA) and mean diffusivity showed global WM integrity differences between patients and controls. Voxel-based and tractography analyses showed significant decreases in FA within centroaxial structures involved in TAI. All three techniques were associated with functional and cognitive outcomes. DTI measures of microstructural integrity appear robust, as the three analysis techniques studied showed adequate utility for detecting WM injury.

Assessing spatial relationships between axonal integrity, regional brain volumes, and neuropsychological outcomes after traumatic axonal injury.

Diffuse traumatic axonal injury (TAI) is a type of traumatic brain injury (TBI) characterized predominantly by white matter damage. While TAI is associated with cerebral atrophy, the relationship between gray matter volumes and TAI of afferent or efferent axonal pathways remains unknown. Moreover, it is unclear if deficits in cognition are associated with post-traumatic brain volumes in particular regions. The goal of this study was to determine the relationship between markers of TAI and volumes of cortical and subcortical structures, while also assessing the relationship between cognitive outcomes and regional brain volumes. High-resolution magnetic resonance imaging scans were performed in 24 patients with TAI within 1 week of injury and were repeated 8 months later. Diffusion tensor imaging (DTI) tractography was used to reconstruct prominent white matter tracts and calculate their fractional anisotropy (FA) and mean diffusivity (MD) values. Regional brain volumes were computed using semi-automated morphometric analysis. Pearson's correlation coefficients were used to assess associations between brain volumes, white matter integrity (i.e., FA and MD), and neuropsychological outcomes. Post-traumatic volumes of many gray matter structures were associated with chronic damage to related white matter tracts, and less strongly associated with measures of white matter integrity in the acute scans. For example, left and right hippocampal volumes correlated with FA in the fornix body (r = 0.600, p = 0.001; r = 0.714, p < 0.001, respectively). In addition, regional brain volumes were associated with deficits in corresponding neuropsychological domains. Our results suggest that TAI may be a primary mechanism of post-traumatic atrophy, and provide support for regional morphometry as a biomarker for cognitive outcome after injury.

Regionally selective atrophy after traumatic axonal injury.

OBJECTIVES: To determine the spatial distribution of cortical and subcortical volume loss in patients with diffuse traumatic axonal injury and to assess the relationship between regional atrophy and functional outcome. DESIGN: Prospective imaging study. Longitudinal changes in global and regional brain volumes were assessed using high-resolution magnetic resonance imaging-based morphometric analysis. SETTING: Inpatient traumatic brain injury unit. PATIENTS OR OTHER PARTICIPANTS: Twenty-five patients with diffuse traumatic axonal injury and 22 age- and sex-matched controls. MAIN OUTCOME MEASURE: Changes in global and regional brain volumes between initial and follow-up magnetic resonance imaging were used to assess the spatial distribution of posttraumatic volume loss. The Glasgow Outcome Scale-Extended score was the primary measure of functional outcome. RESULTS: Patients underwent substantial global atrophy with mean whole-brain parenchymal volume loss of 4.5% (95% confidence interval, 2.7%-6.3%). Decreases in volume (at a false discovery rate of 0.05) were seen in several brain regions including the amygdala, hippocampus, thalamus, corpus callosum, putamen, precuneus, postcentral gyrus, paracentral lobule, and parietal and frontal cortices, while other regions such as the caudate and inferior temporal cortex were relatively resistant to atrophy. Loss of whole-brain parenchymal volume was predictive of long-term disability, as was atrophy of particular brain regions including the inferior parietal cortex, pars orbitalis, pericalcarine cortex, and supramarginal gyrus. CONCLUSION: Traumatic axonal injury leads to substantial posttraumatic atrophy that is regionally selective rather than diffuse, and volume loss in certain regions may have prognostic value for functional recovery.

The influence of minority status on job stability after traumatic brain injury.

OBJECTIVE: To determine the influence of minority status on job stability after traumatic brain injury (TBI). SETTING: TBI Model Systems Centers. PARTICIPANTS: 633 individuals (414 Caucasians vs. 219 Minorities) with primarily moderate to severe TBI hospitalized at one of the TBI Model Systems Centers between 1988 and 2001 with 3 years of continuous follow up employment data after discharge. MAIN OUTCOME MEASURES: Job stability was defined as "stable" (competitively employed at all three follow-up visits), "unemployed" (not competitively employed at all three visits), and "unstable" (any other mixture of competitively employed and not competitively employed over the three follow-up visits). METHODS: A multinomial logistic regression model was used to model the effect of ethnicity on job stability post TBI after adjusting for injury and demographic characteristics. RESULTS: Compared to Caucasians, the adjusted odds for minorities were 3.587 times greater for being unemployed versus being stably employed (95% CI = 1.930, 6.668), 1.911 times greater for being unstably employed versus being stably employed (95% CI = 1.006, 3.628), and 1.878 times more greater for being unemployed versus being unstably employed (95% CI = 1.157, 3.046) after adjusting for preinjury employment status, age, marital status, education, cause of injury, total length of stay in acute and rehabilitation hospitals, and DRS at discharge. CONCLUSIONS: Minority status is an independent predictor of short-term job stability after TBI. Minority TBI survivors were more likely than Caucasians to be unemployed or unstably employed. Rehabilitation professionals should develop employment interventions that will address the specific needs of these racial/ethnic groups and facilitate optimal employment outcomes for minority TBI survivors.

Item analysis of three Spanish naming tests: a cross-cultural investigation.

Neuropsychological evaluations conducted in the United States and abroad commonly include the use of tests translated from English to Spanish. The use of translated naming tests for evaluating predominately Spanish-speakers has recently been challenged on the grounds that translating test items may compromise a test's construct validity. The Texas Spanish Naming Test (TNT) has been developed in Spanish specifically for use with Spanish-speakers; however, it is unlikely patients from diverse Spanish-speaking geographical regions will perform uniformly on a naming test. The present study evaluated and compared the internal consistency and patterns of item-difficulty and -discrimination for the TNT and two commonly used translated naming tests in three countries (i.e., United States, Colombia, Spain). Two hundred fifty two subjects (136 demented, 116 nondemented) across three countries were administered the TNT, Modified Boston Naming Test-Spanish, and the naming subtest from the CERAD. The TNT demonstrated superior internal consistency to its counterparts, a superior item difficulty pattern than the CERAD naming test, and a superior item discrimination pattern than the MBNT-S across countries. Overall, all three Spanish naming tests differentiated nondemented and moderately demented individuals, but the results suggest the items of the TNT are most appropriate to use with Spanish-speakers. Preliminary normative data for the three tests examined in each country are provided.

Cerebral atrophy after traumatic white matter injury: correlation with acute neuroimaging and outcome.

Traumatic brain injury (TBI) is a pathologically heterogeneous disease, including injury to both neuronal cell bodies and axonal processes. Global atrophy of both gray and white matter is common after TBI. This study was designed to determine the relationship between neuroimaging markers of acute diffuse axonal injury (DAI) and cerebral atrophy months later. We performed high-resolution magnetic resonance imaging (MRI) at 3 Tesla (T) in 20 patients who suffered non-penetrating TBI, during the acute (within 1 month after the injury) and chronic stage (at least 6 months after the injury). Volume of abnormal fluid-attenuated inversion-recovery (FLAIR) signal seen in white matter in both acute and follow-up scans was quantified. White and gray matter volumes were also quantified. Functional outcome was measured using the Functional Status Examination (FSE) at the time of the chronic scan. Change in brain volumes, including whole brain volume (WBV), white matter volume (WMV), and gray matter volume (GMV), correlates significantly with acute DAI volume (r = -0.69, -0.59, -0.58, respectively; p <0.01 for all). Volume of acute FLAIR hyperintensities correlates with volume of decreased FLAIR signal in the follow-up scans (r = -0.86, p < 0.001). FSE performance correlates with acute hyperintensity volume and chronic cerebral atrophy (r = 0.53, p = 0.02; r = -0.45, p = 0.03, respectively). Acute axonal lesions measured by FLAIR imaging are strongly predictive of post-traumatic cerebral atrophy. Our findings suggest that axonal pathology measured as white matter lesions following TBI can be identified using MRI, and may be a useful measure for DAI-directed therapies.

Diffusion tensor tractography of traumatic diffuse axonal injury.

BACKGROUND: Diffuse axonal injury is a common consequence of traumatic brain injury that frequently involves the parasagittal white matter, corpus callosum, and brainstem. OBJECTIVE: To examine the potential of diffusion tensor tractography in detecting diffuse axonal injury at the acute stage of injury and predicting long-term functional outcome. DESIGN: Tract-derived fiber variables were analyzed to distinguish patients from control subjects and to determine their relationship to outcome. SETTING: Inpatient traumatic brain injury unit. PATIENTS: From 2005 to 2006, magnetic resonance images were acquired in 12 patients approximately 7 days after injury and in 12 age- and sex-matched controls. MAIN OUTCOME MEASURES: Six fiber variables of the corpus callosum, fornix, and peduncular projections were obtained. Glasgow Outcome Scale-Extended scores were assessed approximately 9 months after injury in 11 of the 12 patients. RESULTS: At least 1 fiber variable of each region showed diffuse axonal injury-associated alterations. At least 1 fiber variable of the anterior body and splenium of the corpus callosum correlated significantly with the Glasgow Outcome Scale-Extended scores. The predicted outcome scores correlated significantly with actual scores in a mixed-effects model. CONCLUSION: Diffusion tensor tractography-based quantitative analysis at the acute stage of injury has the potential to serve as a valuable biomarker of diffuse axonal injury and predict long-term outcome.

Impact of age on long-term recovery from traumatic brain injury.

OBJECTIVE: To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI). DESIGN: Longitudinal cohort study. SETTING: Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers. PARTICIPANTS: Subjects enrolled in the TBIMS national dataset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended. RESULTS: Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (> or =40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates. CONCLUSIONS: This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.

Racial differences in employment outcomes after traumatic brain injury.

OBJECTIVE: To examine racial differences in employment status and occupational status 1 year after a traumatic brain injury (TBI). DESIGN: Retrospective study. SETTING: Longitudinal dataset of the Traumatic Brain Injury Model Systems national database. PARTICIPANTS: Subjects with primarily moderate to severe TBI (3468 whites vs 1791 minorities) hospitalized between 1989 and 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status (competitively employed or unemployed) and occupational status (professional/managerial, skilled, or manual labor) at 1 year postinjury. RESULTS: Race and/or ethnicity has a significant effect on employment status at 1 year postinjury (chi(1)(2)=58.23, P<.001), after adjusting for preinjury employment status, sex, Disability Rating Scale at discharge, marital status, cause of injury, age, and education. The adjusted odds of being unemployed versus competitively employed are 2.17 times (95% confidence interval, 1.78-2.65) greater for minorities than for whites. Race and ethnicity does not have a significant effect on occupational status at 1 year postinjury. CONCLUSIONS: With this empirical evidence supporting racial differences in employment outcomes between minorities and whites at 1 year postinjury, priority should be given to tailoring interventions to maximize minority survivors' work-related productivity.