The Journal of head trauma rehabilitation

Published by Lippincott, Williams & Wilkins
Print ISSN: 0885-9701
The Traumatic Brain Injury Act of 1996 and the Children's Health Act of 2000 authorized the Centers for Disease Control and Prevention to conduct several activities associated with traumatic brain injury. This article describes how the Centers for Disease Control and Prevention responded to the legislation in 2 key areas: traumatic brain injury surveillance, and education and awareness.
: To determine trends for in-hospital survival and functional outcomes at acute care hospital discharge for patients with severe adult traumatic brain injury (SATBI) in Pennsylvania, during 1998 to 2007. : Secondary analysis of the Pennsylvania trauma outcome study database. : Survival and functional status scores of 5 domains (feeding, locomotion, expression, transfer mobility, and social interaction) fitted into logistic regression models adjusted for age, sex, race, comorbidities, injury mechanism, extracranial injuries, severity scores, hospital stay, trauma center, and hospital level. Sensitivity analyses for functional outcomes were performed. : There were 26 234 SATBI patients. Annual numbers of SATBI increased from 1757 to 3808 during 1998 to 2007. Falls accounted for 47.7% of all SATBI. Survival increased significantly from 72.5% to 82.7% (odds ratio [OR] = 1.10, 95% CI: 1.08-1.11, P < .001). In sensitivity analyses, trends of complete independence in functional outcomes increased significantly for expression (OR = 1.01, 95% CI: 1.00-1.02, P = .011) and social interaction (OR = 1.01, 95% CI: 1.00-1.03, P = .002). There were no significant variations over time for feeding, locomotion, and transfer mobility. : Trends for SATBI served by Pennsylvania's established trauma system showed increases in rates but substantial reductions in mortality and significant improvements in functional outcomes at discharge for expression and social interaction.
In 1998, an NIH sponsored Consensus Conference on Traumatic Brain Injury (TBI) Rehabilitation identified 30 different areas of needed research. A comprehensive review of recently generated research knowledge in the field of TBI has shown that a large number of Class III and IV evidence studies have been published, but relatively few of the more scientifically rigorous Class I or II studies. A rapid growth of publications on TBI rehabilitation has generated new knowledge in the epidemiology of TBI, the management of TBI and its secondary medical complications, rehabilitation of cognitive impairment, impact of TBI on community integration and quality of life, incidence of psychiatric dysfunction, and how caregivers and family members are affected. However, there is need to replicate many of these studies using more scientifically rigorous methodologies, while other areas of important TBI research remain largely unexplored.
Traumatic brain injury (TBI) negatively impacts long-term survival. However, little is known about the likelihood of death within the first year following hospital discharge. This study examined mortality among a representative sample of 3679 persons within 1 year of being discharged from any of 62 acute care hospitals in South Carolina following TBI and identified the factors associated with early death using a multivariable Cox proportional hazards model. The mortality experience of the cohort was also compared with that of the general population by using standardized mortality ratios for selected causes of death by age, adjusted for race and sex.
To document age-related patterns of nonfatal hospitalization associated with traumatic brain injury (TBI) among children younger than 2 years of age, by intent/cause and diagnosis. Data describing 2536 nonfatal TBI-related hospitalizations in 15 states for the year 1999 were obtained from the Centers for Disease Control and Prevention Central Nervous System Injury surveillance system for children younger than 2 years of age (0-23 months) at the time of injury. Incidence rates (overall, by intent/cause, and by diagnosis) were calculated by combining TBI surveillance data with population data from the US Census Bureau and the National Center for Health Statistics. Overall rates of nonfatal TBI-related hospitalization peaked at 1 month of age (178.0 cases per 100,000 person-years) followed by a secondary peak at 8 months of age (127.9 cases per 100,000 person-years). Rates for fall-related (unintentional) cases and assault-related cases were significantly higher for infants (0-11 months) than for 1-year-olds (12-23 months), with rates for both types of cases peaking in the earliest months of life. Rates for cases with diagnoses of skull fracture and/or intracranial injury were also significantly higher for the younger group. Assault-related cases frequently coincided with a diagnosis of intracranial injury regardless of age. Prevention efforts should focus on falls and assaults, which account for the majority of TBI-related hospitalizations in early childhood. Such efforts may also need to emphasize the unusually high risk during the first few months of life.
Traumatic brain injury (TBI) is an important public health problem in the United States. In 2003, there were an estimated 1,565,000 TBIs in the United States: 1,224,000 emergency department visits, 290,000 hospitalizations, and 51,000 deaths. Findings were similar to those from previous years in which rates of TBI were highest for young children (aged 0-4) and men, and the leading causes of TBI were falls and motor vehicle traffic.
Develop and validate a predictive model of the incidence of long-term disability following traumatic brain injury (TBI) and obtain national estimates for the United States in 2003. DATA/METHODS: A logistic regression model was built, using a population-based sample of persons with TBI from the South Carolina Traumatic Brain Injury Follow-up Registry. The regression coefficients were applied to the 2003 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample data to estimate the incidence of long-term disability following traumatic brain injury hospitalization. Among 288,009 (95% CI, 287,974-288,043) hospitalized TBI survivors in the United States in 2003, an estimated 124,626 (95% CI, 123,706-125,546) had developed long-term disability. TBI-related disability is a significant public health problem in the United States. The substantial incidence suggests the need for comprehensive rehabilitative care and services to maximize the potential of persons with TBI.
To estimate the prevalence of long-term disability associated with traumatic brain injury (TBI) in the civilian population of the United States. We first estimated how many people experienced long-term disability from TBI each year in the past 70 years. Then, accounting for the increased mortality among TBI survivors, we estimated their life expectancy and calculated how many were expected to be alive in 2005. An estimated 1.1% of the US civilian population or 3.17 million people (95% CI: 3.02-3.32 million) were living with a long-term disability from TBI at the beginning of 2005. Under less conservative assumptions about TBI's impact on lifespan, this estimate is 3.32 million (95% CI: 3.16-3.48 million). Substantial long-term disability occurs among the US civilians hospitalized with a TBI.
Over the last 20 years, numerous papers that are relevant to understanding the problem of impaired self-awareness after moderately severe to severe traumatic brain injury have appeared. This article reviews many of these papers and summarizes salient findings relevant to rehabilitation and future research.
Evaluate an intervention to improve an alliance between an interdisciplinary team and clients with traumatic brain injury attending post-acute brain injury rehabilitation. Prospective design, 2 consecutive samples-historical control (CNT) and treatment (TX). Sample of 104 clients (69 CNT, 35 TX) admitted to post-acute brain injury rehabilitation completed admit/discharge questionnaires. The TX group had higher functional status at discharge than the CNT group. Stronger team alliance was associated with program completion, return to productivity, stronger client alliance, less family discord, and fewer depressive symptoms. Findings provide direction for a larger study examining the effectiveness of this intervention to improve outcome after traumatic brain injury.
To examine the epidemiologic and clinical characteristics of older persons (ie, those aged 65-74, 75-84, and > or = 85 years) hospitalized with traumatic brain injury (TBI). Data from the 1999 CDC 15-state TBI surveillance system were analyzed. In 1999, there were 17,657 persons 65 years and older hospitalized with TBI in the 15 states for an age-adjusted rate of 155.9 per 100,000 population. Rates among persons aged 65 years or older increased with age and were higher for males. Most TBIs resulted from fall- or motor vehicle (MV)-traffic-related incidents. Most older persons with TBI had an initial TBI severity of mild (73.4%); however, the proportions of both moderate and severe disability for those discharged alive and of in-hospital mortality were relatively high (23.5%, 9.7%, and 12%, respectively). Persons who fell were also more likely to have had 3 or more comorbid conditions than were those who sustained a TBI from an MV-traffic incident. TBI is a substantial public health problem among older persons. As the population of older persons continues to increase in the United States, the need to design and implement proven and cost-effective prevention measures that focus on the leading causes of TBI (unintentional falls and MV-traffic incidents) becomes more urgent.
To investigate the relevance of the Symptom Checklist 90-R Obsessive-Compulsive subscale to cognition in individuals with brain tumor. A prospective study of patients assessed with a neuropsychological test battery. A university medical center. Nineteen adults with biopsy-confirmed diagnoses of malignant brain tumors were assessed prior to aggressive chemotherapy. Included in the assessment were the Mattis Dementia Rating Scale, California Verbal Learning Test, Trail Making Test B, Symptom Checklist 90-R, Mood Assessment Scale, Beck Anxiety Inventory, and Chronic Illness Problem Inventory. The SCL 90-R Obsessive-Compulsive subscale was not related to objective measures of attention, verbal memory, or age. It was related significantly to symptoms of depression (r = .81, P < .005), anxiety (r = .66, P < .005), and subjective complaints of memory problems (r = .75, P < .005). Multivariate analyses indicated that reported symptoms of depression contributed 66% of the variance in predicting SCL 90-R Obsessive-Compulsive Scores, whereas symptoms of anxiety contributed an additional 6% (P < .0001). Our data suggest that the SCL 90-R is best viewed as an indicator of unidimensional emotional distress and somatic effects of structural brain injury.
To identify social, neuroradiological, medical, and neuropsychological correlates of sexually aberrant behavior (SAB) after traumatic brain injury (TBI). A controlled study using a retrospective file review. A brain injury unit providing inpatient and outpatient rehabilitation services. A sample of males (n = 25) exhibiting SABs and a control group (n = 25) matched for gender, severity of injury, age at injury, and time after injury. A protocol that recorded data on demographic, injury, radiological, medical, and neuropsychological variables. The SAB group had a significantly higher incidence of postinjury psychosocial disturbance in areas of nonsexual crime and failure to return to work than the matched TBI group. There were no significant differences between the two groups in the incidence of premorbid psychosocial disturbance or postinjury radiological, medical, or neuropsychological variables. The study results caution against simplistic explanations of SAB as the product of damage to the frontal-lobe systems or premorbid psychosocial disturbance. Furthermore, the results suggest that a wide-ranging assessment of people with TBI who exhibit SABs is required, because results of neuropsychological examination alone cannot be considered conclusive. Future research into the etiology of SABs could examine additional factors such as lack of insight, lack of empathy, and premorbid history of family dysfunction.
To evaluate the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for persons with traumatic brain injury (TBI). Prospective cohort study. A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care or inpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 months postinjury). La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig Handicap Assessment and Reporting Technique-Short Form Social Integration subscale (CHART-SF-SI), Community Integration Questionnaire Social Integration subscale (CIQ-SI). Social communication measures (LCQ, AIPSS) and self-reported behavioral functioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographic and injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioral variables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI. Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.
Use a longitudinal birth cohort to evaluate the association of traumatic brain injury at ages 0 to 5, 6 to 15, and 16 to 21 years with drug and alcohol abuse and engagement in criminal activities. Follow-up over 21 to 25 years using self-report of drug and alcohol use, arrests, and violent and property offenses. Outcomes were assessed for 2 levels of severity (inpatient, hospitalized; outpatient, seen by general practitioner or at emergency department). Members of the Christchurch Health and Development Study, a longitudinal birth cohort. Christchurch, New Zealand. Adjusted for child and family factors, compared with noninjured individuals, inpatients injured at 0 to 5 years or 16 to 21 years were more likely to have symptoms consistent with drug dependence. All inpatient groups had increased risk of arrest, with the age groups of 0 to 5 and 6 to 15 years more likely to be involved in violent offenses and the age group of 0 to 5 years more likely to engage in property offenses. Outpatient group had an increased risk of violent offenses for first injury 0 to 5 years, arrests and property offenses for injury 6 to 15 years, and increased risk of arrests and violent offenses for injury 16 to 21 years of age. However, when alcohol dependence and drug dependence were added as an additional covariate, traumatic brain injury was no longer associated with criminal behavior for the age group of 0 to 5 years. Traumatic brain injury is associated with increased criminal behavior and may represent a risk factor for offending. However, early substance use is a mediating factor for those injured early in life.
To demonstrate the feasibility of a skills-based substance abuse prevention counseling program in a community setting for adults who sustained traumatic brain injury. Convenience sample of 117 participants (mean age=35 years) with preinjury history of alcohol or other drug use. Intervention group participants (n=36) from 3 vocational rehabilitation programs; a no-intervention comparison group (n=81) from an outpatient rehabilitation service. 12 individual counseling sessions featuring skills-based intervention. Changes in self-reported alcohol and other drug use, coping skillfulness, affect, and employment status from baseline to 9 months postintervention. Significant differences were noted at baseline for the intervention and comparison groups on ethnicity, time postinjury, marital status, and employment (P<.05). At the 9-month follow-up, the intervention group participants achieved a statistically significant decrease in alcohol and drug use (P<.05), increase in coping skillfulness (P<.01), and increased likelihood of maintaining employment (P<.01) relative to the comparison group. Controlling for baseline-adjusted means for the intervention and comparison groups, a statistically significant group difference in adjusted change was noted; the intervention group participants reported lower negative affect at the 9-month follow-up assessment (P<.05). A skills-based intervention provides a promising approach to promoting abstinence from all substances and increasing readiness for employment for adults with traumatic brain injuries in outpatient settings.
Explore the incidence of traumatic brain injury (TBI) in veterans seeking outpatient substance abuse treatment and the association between TBI and psychiatric diagnoses. The Ohio State University TBI identification method (OSU TBI-ID) was administered to veterans with positive TBI-4 screens; substance-related and psychiatric diagnoses were extracted from the medical record. : Over an 18-month period, 247 veterans completed the TBI-4. Of the 136 who screened positive, 70 were administered the OSU TBI-ID. On the basis of the TBI-4, 55% (95% CI: 49%-61%) of veterans screened positive for a history of TBI. The OSU TBI-ID was used to confirm screening results. Those who completed the OSU TBI-ID sustained an average of 3.4 lifetime TBIs. For each additional TBI sustained, after initial injury, there was an estimated 9% increase in the number of psychiatric diagnoses documented (99% CI: 1%-17%). For each additional documented psychiatric diagnosis, there was an estimated increase of 11% in the number of injuries sustained (99% CI: 1%-22%). Also, 54% (38/70) had a positive history of TBI prior to adulthood. These results emphasize the need for TBI screening in this vulnerable population, as well as the importance of increasing brain injury awareness among those abusing substances and their care providers. These findings also highlight the need for specialized services for those with TBI and co-occurring substance misuse aimed at decreased future TBIs or negative psychiatric outcomes or both. Further study is needed to clarify best practices.
Residual emotional and behavioral difficulties in individuals who have sustained a traumatic brain injury (TBI) have been well documented in the literature. The issues are complex, interdependent, and often include substance abuse, depression, anxiety, chronic suicidal or homicidal ideation, poor impulse control, and significant degrees of frustration and anger. Often, preexisting psychological conditions and poor coping strategies are exacerbated by the trauma. Emotional and behavioral difficulties can interfere with the neurorehabilitation process at all levels. In acute rehabilitation, these issues have traditionally been addressed on an individual basis. However, in postacute settings, an interpersonal group format can be effectively implemented. The majority of individuals with TBI have minimal funding for long-term cognitive and behavioral remediation; often the only avenue available is support groups. This article will describe group psychotherapy models used with individuals with acute or postacute TBI within a comprehensive rehabilitation center. Interdisciplinary treatment of frustration and substance abuse and a continuum of care will be emphasized. Education, social support, skills development, interpersonal process, and cognitive-behavioral approaches will also be discussed. The psychotherapy groups focus on treatment of substance abuse and frustration management through education, social support, and development of interpersonal skills. Practical considerations of running such groups are presented.
To examine clinical characteristics of clients in state-funded substance abuse treatment who report traumatic brain injury with loss of consciousness (TBI-LOC). Adult clients (N = 7784) entering state-funded substance abuse treatment in a rural state during a 12-month period. MEASUREMENT TOOLS: Substance use and mental health problems were measured using the federal Substance Abuse and Mental Health Services Administration (SAMHSA) adaptation of the Addiction Severity index (ASI). A brain injury screening question was used to determine the number of TBI-LOCs in a client's lifetime. Cross-sectional study of intake characteristics as part of a state-mandated treatment outcome study. Almost one-third (31.7%) of substance abuse treatment clients reported 1 or more TBI-LOCs. The clients reporting 2 or more TBI-LOCs were more likely than clients with none or 1 TBI-LOC to have serious mental health problems (ie, depression, anxiety, hallucinations, and suicidal thoughts and attempts), trouble controlling violent behavior, trouble concentrating or remembering, and more months of use of most substances. When depression and anxiety were held constant, and controlling for race and gender, clients with TBI-LOC had more months of marijuana and tranquilizer use. Findings suggest that treatment providers may need to be attentive to the complex conditions that co-occur with TBI-LOC. Future research should examine whether there are differences in treatment outcome for clients reporting TBI-LOC.
Violence, abuse, and neglect (VAN) among people with physical and other disabilities has been reported; however, little is known about VAN experiences among people with traumatic brain injuries (TBI). Nine people who reported experiencing VAN post-TBI were interviewed for this phenomenological study. The data were analyzed to understand VAN as experienced by those with TBI. Participants detailed many VAN experiences along with contributing factors, barriers in obtaining help, and recommendations for improving preventive and assistance services. Greater efforts are needed to identify and prevent VAN among people with TBI. Services following VAN must be improved.
Within the expanding field of clinical neuropsychology, the subspecialty of forensic neuropsychology has developed. Currently, there is considerable diversity within the discipline as to how practitioners approach test selection, reports, and number of hours billed. How individuals handle these issues is subject to debate, but what is clear is that there are no specific guidelines as to how to conduct these evaluations. The current study provides an introduction to the issues faced by clinical neuropsychologists completing forensic evaluations. In addition, the authors present how the relevant issues are addressed in one neuropsychology service housed within a university-affiliated academic medical center.
Delineate the effects of self-reported traumatic brain injury (TBI) or posttraumatic stress disorder (PTSD) on self-regulated learning and academic achievement for university-enrolled military Service members. Students (N = 192) from 8 regionally diverse universities, representing an estimated 6% of Service members enrolled across schools. Public universities that are members of the Servicemember Opportunity College consortium. Cross-sectional study evaluating the relationships between self-reported TBI, PTSD, and self-regulated learning variables and their contribution to academic achievement. Self-report of military service; symptoms of TBI and PTSD; self-regulation strategies including effort, time/environment regulation, and academic self-efficacy; and grade point average (GPA). There was no effect of self-reported TBI or PTSD on GPA, effort regulation, or time/environment regulation strategies; however, participants with TBI or PTSD reported significantly lower academic self-efficacy. Multiple regression analysis revealed self-efficacy was the strongest predictor of GPA among all participants, followed by military rank. The sample consisted of high achieving students responsive to a university administrator, which raises the possibility of sampling bias. Because of the low recruitment rate for this study and lack of published research on this subject, replicating the results is necessary before drawing generalizable conclusions about the population.
To determine the influence of preexisting heart, liver, kidney, cancer, stroke, and mental health problems and examine the influence of low socioeconomic status on mortality after discharge from acute care facilities for individuals with traumatic brain injury. Population-based retrospective cohort study of 33 695 persons discharged from acute care hospital with traumatic brain injury in South Carolina, 1999-2010. Days elapsing from the dates of injury to death established the survival time (T). Data were censored at the 145th month. Multivariable Cox regression was used to examine the independent effect of the variables on death. Age-adjusted cumulative probability of death for each chronic disease of interest was plotted. By the 70th month of follow-up, rate of death was accelerated from 10-fold for heart diseases to 2.5-fold for mental health problems. Adjusted hazard ratios for diseases of the heart (2.13), liver-renal (3.25), cancer (2.64), neurological diseases and stroke (2.07), diabetes (1.89), hypertension (1.43), and mental health problems (1.59) were highly significant (each with P < .001). Compared with persons with private insurance, the hazard ratio was significantly elevated with Medicaid (1.67), Medicare (1.54), and uninsured (1.27) (each with P < .001). Specific chronic diseases strongly influenced postdischarge mortality after traumatic brain injury. Low socioeconomic status as measured by the type of insurance elevated the risk of death.
This study compared the accuracy of artificial neural networks to multiple regression and classification and regression trees in predicting outcomes of 1,644 patients in the Traumatic Brain Injury Model Systems database 1 year after injury. Data from rehabilitation admission were used to predict discharge scores on the Functional Independence Measure, the Disability Rating Scale, and the Community Integration Questionnaire. Artificial neural networks did not demonstrate greater accuracy in predicting outcomes than did the more widely used method of multiple regression. Both of these methods outperformed classification and regression trees. Because of the sophisticated form of multiple regression with splines that was used, firm conclusions are limited about the relative accuracy of artificial neural networks compared to more widely used forms of multiple regression.
1 H magnetic resonance scout image of a healthy volunteer showing the optimal positioning of the single voxel located adjacent to the cortical-subcortical junction, just anteriorly to the frontal horn of the lateral ventricle, at the same height of a virtual plane positioned just above the corpus callosum, to include only the white matter of the frontal lobes, bilaterally. The proton spectrum shows the peaks corresponding to the metabolites of interest N -acetylaspartate (NAA), creatine (Cr), and choline (Cho). The calculated NAA/Cr and Cho/Cr ratios, relative to this subject, are also indicated. 
Bar graph showing the metabolite ratios of N-acetylaspartate/creatine-containing compounds (NAA/Cr) in controls and patients with concussive head injury. Each bar is the mean value determined in 11 healthy controls and 11 athletes with concussive head injury. Standard deviations are represented by vertical bars. At 3 and 15 days, the NAA/Cr ratio increased by 24.3% and 16.5%, respectively, whereas at 30 days postinjury, it decreased by 10.6%. Normalization was observed 45 days after concussion. a P < .05 with respect to controls.
Bar graph showing the metabolite ratios of N-acetylaspartate/choline-containing compounds (NAA/Cho) in controls and patients with concussive head injury. Each bar is the mean value determined in 11 healthy controls and 11 athletes with concussive head injury. Standard deviations are represented by vertical bars. At 3, 15, and 30 days postinjury the NAA/Cho ratio decreased by 17.0%, 20.1%, and 12.4%, respectively. Normalization was observed 45 days after concussion. a P < .05 with respect to controls.
Representative 1 H magnetic resonance spectra recorded in a healthy control subject and in a concussed athlete at 3, 30, and 45 days postinjury (for graphical reasons, the 15-day spectrum was not reported). Decrease (3 days), recovery (30 days), and subsequent normalization (45 days) in the NAA and Cr peaks and no change in the peak of Cho are clearly visible in the spectra of the postconcussed athlete. 
Objectives: To assess the time course changes in N-acetylaspartate (NAA) and creatine (Cr) levels in the brain of athletes who suffered a sport-related concussion. Participants: Eleven nonconsecutive athletes with concussive head injury and 11 sex- and age-matched control volunteers Main outcome measures: : At 3, 15, 30, and 45 days postinjury, athletes were examined by proton magnetic resonance spectroscopy for the determination of NAA, Cr, and choline (Cho) levels. Proton magnetic resonance spectroscopic data recorded for the control group were used for comparison. Results: Compared with controls (2.18 ± 0.19), athletes showed an increase in the NAA/Cr ratio at 3 (2.71 ± 0.16; P < .01) and 15 (2.54 ± 0.21; P < .01) days postconcussion, followed by a decrease and subsequent normalization at 30 (1.95 ± 0.16, P < .05) and 45 (2.17 ± 0.20; P < .05) days postconcussion. The NAA/Cho ratio decreased at 3, 15, and 30 days postinjury (P < .01 compared with controls), with no differences observed in controls at 45 days postconcussion. Compared with controls, significant increase in the Cho/Cr ratio after 3 (+33%, P < .01) and 15 (+31.5%, P < .01) days postinjury was observed whereas no differences were recorded at 30 and 45 days postinjury. Conclusions: This cohort of athletes indicates that concussion may cause concomitant decrease in cerebral NAA and Cr levels. This provokes longer time for normalization of metabolism, as well as longer time for resolution of concussion-associated clinical symptoms.
This study investigated the effects of a cognitive-behavioral intervention on the escalating behavior problems observed in 2 children with severe traumatic brain injury. Multiple baseline designs were used to document the effects of an intervention package that integrated cognitive and executive function interventions to address severe challenging behaviors in public school settings. The results suggested that the intervention reduced the frequency and intensity of challenging behaviors and increased the quantity of work completed. These 2 successful single-subject experiments expand the findings of previous studies on the use of a support-oriented intervention that uses context-sensitive, flexible cognitive/behavioral scripts combined with positive behavior interventions and supports to reduce challenging behaviors.
Study characteristics a (Continued) 
Patient characteristics a (Continued) 
Patient characteristics a (Continued) 
Intervention characteristics (Continued) 
Intervention characteristics (Continued) 
To review and evaluate the effectiveness and methodological quality of available treatment methods for unawareness of deficits after acquired brain injury (ABI). Systematic literature search for treatment studies for unawareness of deficits after ABI. Information concerning study content and reported effectiveness was extracted. Quality of the study reports and methods were evaluated. A total of 471 articles were identified; 25 met inclusion criteria. 16 were uncontrolled or single-case studies. Nine were of higher quality: 2 randomized controlled trials, 5 single case experimental designs, 1 single-case design with pre- and posttreatment measurement, and 1 quasi-experimental controlled design. Overall, interventions consisted of multiple components including education and multimodal feedback on performance. Five of the 9 high-quality studies reported a positive effect of the intervention on unawareness in patients with some knowledge of their impairments. Effect sizes ranged from questionable to large. Patients with ABI may improve their awareness of their disabilities and possibly attain a level at which they personally experience problems when they occur. At present, because of lack of evidence, no recommendation can be made for treatment approaches for persons with severe impairment of self-awareness in the chronic phase of ABI. We recommended developing and evaluating theory-driven interventions specifically focused on disentangling the components of treatment that are successful in improving awareness. High-quality intervention studies are urgently needed using controlled designs (eg, single-case experimental designs, randomized controlled trials) based on a theoretic perspective with a detailed description of the content of the intervention and suitable outcome measures.
This study evaluated the relative efficacy of a community rehabilitation service and a more traditional outpatient service for carers of people with an acquired brain injury. Seventeen carers who had received a community intervention were retrospectively compared with 24 carers who had received an outpatient service. Dependent variables were level of met family need, a measure of family dysfunction, carer psychopathology, and carer emotional acceptance. The community sample fared significantly better on all measures except carer psychopathology. These results suggest that community-based services have efficacy for the carer and family. There is a clear need for large clinical trials using standardized instruments to establish what models of service delivery benefit carers.
Background: Impaired self-awareness is a potential obstacle to successful rehabilitation. Objective: To obtain clinicians' ratings of the importance of self-awareness for brain injury rehabilitation and use of instruments to assess self-awareness. Participants: One hundred sixty-three members of 3 major Dutch organizations for neuropsychology or rehabilitation. Main measure: Online survey addressing: (1) factors participants consider important for the course and success of rehabilitation, (2) whether they assess patients' levels of self-awareness, and (3) the instruments they use to do so. Results: Of the 163 respondents, 116 (71.2%) considered self-awareness to be important for the course of rehabilitation; 113 (69.3%) considered it to be important for the success of rehabilitation. One hundred fifty-six clinicians (95.7%) reported assessing patients' levels of self-awareness, but only 12 (7.4%) reported using standardized instruments specifically designed for this purpose. The instruments most frequently reported to be used were the Awareness Questionnaire and Patient Competency Rating Scale. Conclusions: It is difficult to capture different aspects of self-awareness in a standardized manner. There is a need for instruments that are valid and reliable and that have good clinical utility.
T1/T2-weighted magnetic resonance imaging abnormalities 
Characteristics of study population (N = 52)
Objective: To understand the relations of mild traumatic brain injury (TBI), blast exposure, and brain white matter structure to severity of posttraumatic stress disorder (PTSD). Design: Nested cohort study using multivariate analyses. Participants: Fifty-two OEF/OIF veterans who served in combat areas between 2001 and 2008 were studied approximately 4 years after the last tour of duty. Main measures: PTSD Checklist-Military; Combat Experiences Survey, interview questions concerning blast exposure and TBI symptoms; anatomical magnetic resonance imaging (MRI), and diffusion tensor imaging (DTI) scanning of the brain. Results: PTSD severity was associated with higher 1st percentile values of mean diffusivity on DTI (regression coefficient [r] = 4.2, P = .039), abnormal MRI (r = 13.3, P = .046), and the severity of exposure to combat events (r = 5.4, P = .007). Mild TBI was not significantly associated with PTSD severity. Blast exposure was associated with lower 1st percentile values of fractional anisotropy on DTI (odds ratio [OR] = 0.38 per SD; 95% confidence interval [CI], 0.15-0.92), normal MRI (OR = 0.00, 95% likelihood ratio test CI, 0.00-0.09), and the severity of exposure to traumatic events (OR = 3.64 per SD; 95% CI, 1.40-9.43). Conclusions: PTSD severity is related to both the severity of combat stress and underlying structural brain changes on MRI and DTI but not to a clinical diagnosis of mild TBI. The observed relation between blast exposure and abnormal DTI suggests that subclinical TBI may play a role in the genesis of PTSD in a combat environment.
This study explored the reliability and validity of the Screening Tool for the Identification of Acquired Brain Injury in School-Aged Children (STI). Parents and teachers of students (K-12) from 3 different groups (students with known acquired brain injuries, students with special education needs, and typical students) rated their students' behaviors, symptoms, and injuries using the STI. Test-retest and internal consistency analyses indicated acceptable reliability. Additionally, the 3 activities used to determine test validity all yielded positive results. The STI indicates sensitivity to learning challenges; however, further research is needed to develop instrument specificity. We also introduce the idea of using tools, such as the STI for the purpose of an "educational identification" for students who are in need of immediate support, and for whom no formal medical diagnosis yet exists.
To examine the determinants and correlates of coping styles in the chronic phase following acquired brain injury. Chart review. Outpatient rehabilitation center. One hundred thirty-six persons with an acquired brain injury who were more than 6 months postinjury. Utrecht Coping List, Symptom Checklist 90, Stroop Color Word Test, and the 15-Word Learning Test. Neuropsychological performance did not influence the use of coping styles. Persons with higher levels of educational attainment most often reported active problem-focused coping styles. Persons with a long time period since injury most often used passive reactions. More use of passive coping styles and less seeking of social support contributed significantly to higher levels of subjective complaints. Cognitive functions do not influence coping style. Passive emotion-focused coping styles in the chronic phase after injury are maladaptive. These findings emphasize the importance of training of adaptive coping styles as rehabilitation targets in the chronic phase, especially for persons with lower educational attainment.
: To determine whether combat-acquired traumatic brain injury (TBI) is associated with postdeployment frequent binge drinking among a random sample of active duty military personnel. : Active duty military personnel who returned home within the past year from deployment to a combat theater of operations and completed a survey health assessment (N = 7155). : Cross-sectional observational study with multivariate analysis of responses to the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, an anonymous, random, population-based assessment of the armed forces. : Frequent binge drinking: 5 or more drinks on the same occasion, at least once per week, in the past 30 days. TBI-AC: self-reported altered consciousness only; loss of consciousness (LOC) of less than 1 minute (TBI-LOC <1); and LOC of 1 minute or greater (TBI-LOC 1+) after combat injury event exposure. : Of active duty military personnel who had a past year combat deployment, 25.6% were frequent binge drinkers and 13.9% reported experiencing a TBI on the deployment, primarily TBI-AC (7.5%). In regression models adjusting for demographics and positive screen for posttraumatic stress disorder, active duty military personnel with TBI had increased odds of frequent binge drinking compared with those with no injury exposure or without TBI: TBI-AC (adjusted odds ratio, 1.48; 95% confidence interval, 1.18-1.84); TBI-LOC 1+ (adjusted odds ratio, 1.67; 95% confidence interval, 1.00-2.79). : Traumatic brain injury was significantly associated with past month frequent binge drinking after controlling for posttraumatic stress disorder, combat exposure, and other covariates.
To survey individuals with acquired brain injury to assess multiple facets of interest, access, and familiarity necessary to implement new telerehabilitation technologies. Anonymous mail survey. Setting: Community. Seventy-one respondents to a survey. These individuals had experienced acquired brain injury (predominantly severe traumatic brain injury [TBI]) and were living in the community. Surveys were mailed by a state chapter of the Brain Injury Association to a random selection of members with acquired brain injury. Survey designed specifically for this investigation. The survey responses indicate that there is great interest in the possibility of accessing telerehabilitative services among individuals with acquired brain injury. In particular, there was strong interest expressed in services that could be used to assist with problems in memory, attention, problem-solving, and activities of daily living. Telemedicine, and more specifically telerehabilitation, holds great promise as an adjunct to traditional clinical service delivery. Little research in this area has been applied, however, to individuals with acquired brain injuries. Although on the surface, telerehabilitation seems to be an appropriate assessment and treatment modality for individuals with brain injury, it will only succeed if those individuals have the interest-and the access-necessary to use new and evolving technologies.
OBJECTIVE:: To identify measures of coping styles used by patients with acquired brain injury; to evaluate the conceptualization, feasibility, and psychometric properties of the instruments; and to provide guidance for researchers and clinicians in the choice of a suitable instrument. DESIGN:: Systematic review. RESULTS:: The search identified 47 instruments, of which 14 were selected. The instruments focused on dispositional coping, situation-specific coping, or domain-specific coping. Psychometric properties were scarcely investigated. The COPE stood out in terms of psychometric properties but had low feasibility. The brief COPE, Coping Scale for Adults-short form, and Utrecht Coping List stood out in terms of feasibility, and the available psychometric properties of these instruments were good. Only the Coping With Health Injuries and Problems was used as other report. CONCLUSION:: Information on psychometric properties of coping instruments in acquired brain injury is scarcely available and limits the strength of our recommendations. For patients with mild injuries, we cautiously recommend the COPE and for patients with more severe injuries the brief COPE, Coping Scale for Adults-short form, Utrecht Coping List, and Coping With Health Injuries and Problems-other-report. Other instruments may be used to address particular issues such as coping with a specific stressful situation or illness.
To determine if oral/systemic delivery of baclofen can effectively decrease spastic hypertonia due to acquired brain injury (traumatic brain injury, stroke, anoxia, or encephalopathy). Tertiary care outpatient rehabilitation center directly attached to a university hospital. Patients were a convenience sample recruited consecutively who had been referred for treatment of their spastic hypertonia to our spasticity clinic over a 5-year period. The spastic hypertonia was due to an acquired brain injury by either traumatic brain injury (TBI), stroke, or anoxic brain injury. All patients were more than 6 months postinjury or illness. Retrospective review of patients before and after initiation of treatment with oral baclofen, per standardized clinical data sheets. Thirty-five patients (22 TBI patients) were started on oral baclofen and were reevaluated between 1 to 3 months after initiation of treatment. Data for motor tone (Ashworth scores), spasm scores (Penn spasm frequency score), and deep tendon reflex scores were collected on the affected upper extremity (UE) and lower extremity (LE) side(s). Normal extremities were not assessed. Differences over time were assessed via descriptive statistics and Wilcoxon signed-rank. After 1 to 3 months of treatment when subjects had reached their maximal tolerated dosage, the average LE Ashworth score in the affected lower extremities (LEs) decreased from 3.5 to 3.2 (P =.0003), the reflex score decreased from 2.5 to 2.2 (P =.0274), and there was no statistical difference in the spasm score (P >.05). When the 22 TBI patients are analyzed separately, the average LE Ashworth score decreased from 3.5 to 3.2 (P =.0044) and the reflex score decreased from 2.7 to 2.0 (P =.0003). There was no statistically significant change in UE tone, spasm frequency, or reflexes after 1 to 3 months of treatment (P >.05). The average dosage at follow-up was 57 mg/day of baclofen (range 15-120 mg/day). There was a 17% incidence of somnolence that limited the maximum daily dosage of the medication. The oral delivery of baclofen is capable of reducing LE spastic hypertonia resulting from acquired brain injury. The lack of effect upon the upper extremities may be due to receptor specificity issues. GABA-B receptors may be less involved in the modulation of UE spastic hypertonia.
Background: The development of novel serotonin agents has led to an increased use of these medications throughout medical practice. An understanding of the basic pharmacological function of these agents is key to understanding their usefulness. Among persons with brain injury, serotonin agents have been used for the treatment of depression, panic disorder, obsessive-compulsive disorders, agitation, sleep disorders, and motor dysfunction. Conclusion: This article will review the mechanisms, efficacy, and side effects of serotonin agents with a focus on persons with brain injury.
To conduct and evaluate an educational/consultation program for parents and teachers of children who have acquired brain injury (ABI). Parents, regular and special educators, and related school personnel of 30 students who had ABI and serious school problems. BrainSTARS (Brain Injury: Strategies for Teams and Re-education for Students), an individualized consultation program that includes a comprehensive manual on pediatric ABI. The intervention included 3 meetings in the school of the child identified with ABI. A pre/post single group design assessed the impact of BrainSTARS on ABI-related competencies in the adult participants as well as on measures of child behaviors. Significant improvement was shown in the participants' self-rated proficiency in working with children who have ABI as well as on their ratings of student performance in targeted neurodevelopmental areas. There was no significant change on standardized measures of child behavior (the Behavior Rating Inventory of Executive Functions and the Behavior Assessment System for Children). BrainSTARS appears to increase the competencies of parents and educators related to students who have ABI; further study of BrainSTARS' impact on student performance and capacity to produce long-standing results is called for.
Based on the technologies of applied behavior analysis and person-centered planning, positive behavior support is a process for designing and implementing proactive behavioral interventions with the goal of positive lifestyle changes. The two adolescents who received the intensive, longitudinal, multicomponent intervention had experienced escalating behavior challenges over several years after brain injury in early childhood. Quantitative data included episodes of aggression and property destruction. Qualitative data included intensity of supports, family involvement, peer relationships, medication regime, vocational status, educational status, community access, and self-help skills. A long-term, natural-environment, case-study method was used. The targeted challenging behaviors were reduced to zero. In addition, the participants' domains of activity increased and self-management improved even as supports were systematically withdrawn. These results illustrate the potential for successfully treating extreme chronic behavior disorders after childhood brain injury.
To compare the relative utility of conventional neuropsychological and social problem-solving approaches to measuring functional problem solving deficits in individuals with acquired brain damage (ABD). In Study I, scores for individuals with ABD were compared to scores for control and normative samples. In Study II, pre- and posttest scores were compared for individuals with ABD who completed a program of outpatient cognitive rehabilitation. In Study I, individuals with ABD were compared to healthy controls. In Study II, pre- and posttreatment assessments were obtained for 34 individuals with ABD. Two approaches were used, conventional neuropsychological (WAIS-R/II Comprehension subtest and Wisconsin Card Sorting Test) and social problem solving (Problem Solving Inventory and Rusk Problem Solving Role Play Test). In Study I, the ABD group demonstrated significant deficits on both social problem solving measures; however, neither conventional neuropsychological measure detected significant deficits in the ABD group, relative to control and normative groups. In Study II, significant treatment gains were demonstrated on both social problem-solving measures, however neither conventional neuropsychological measure was sensitive to improvements in functional problem-solving ability. In higher-level cognitive rehabilitation settings, the evaluation of functional problem-solving deficits in individuals with ABD can be facilitated by augmenting neuropsychological test data with results from social problem-solving measures.
Individuals who have acquired brain injury (ABI) may express themselves through the use of challenging behaviors, such as aggression, withdrawal, disinhibition, and self-destructive behaviors. This article describes the effectiveness of behavior interventions derived from the assessment of behavior in a community-based setting. The premise is that behavior, no matter how difficult, has function, purpose, and meaning for the individual. A therapeutic model of behavior assessment is presented that bases its strength on behavior assessment and well-trained staff. A well-formulated behavior management plan is developed, reinforcing alternative behaviors teaching skills, and reducing unwanted behaviors. Through the use of data collection methods, the treatment team identifies variables related to unwanted behavior and outcomes of consequences as they relate to the behavior. Illustrated through a case study, the behavioral treatment model is defined through behavior identification, initial assessments, treatment approaches, and tracking outcomes.
Objective: To further validate the Rivermead Behavioral Memory Test for Children (RBMT-C) for use in children with acquired brain injury (ABI). We hypothesized that the RBMT-C could differentiate between children with and without ABI. We also hypothesized that construct validity would be supported by significant correlations with additional cognitive tests. Method: A total of 58 children (6-11 years old), comprising 29 children diagnosed as having ABI (15 girls, 14 boys) and 29 healthy children (15 girls, 14 boys), participated. Children were administered the RBMT-C and the Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA-Ch). The Functional Independence Measure for Children (WeeFIM) was completed by the staff members. Results: There were significant differences in memory between children with ABI and the healthy children [t (35) = 4.94, P < .00]. Significant correlations were found between memory as measured by the RBMT-C and cognitive status as measured by the DOTCA-Ch, as well as cognitive function scores in the WeeFIM supporting convergent validity. Nonsignificant correlations were found between the motor function scores (WeeFIM) and the memory scores (RBMT-C), supporting divergent validity. Conclusions: The study results suggest that the RBMT-C can differentiate between children with and without memory difficulties. However, further studies are needed to establish the Israeli version validity.
To empirically evaluate a method of treating adolescents with cognitive communication disorders, including pragmatic deficits, secondary to acquired brain injury (ABI) in a group setting by objectively measuring outcomes before treatment and immediately after treatment and at 6 months posttreatment. A before-after trial with follow-up in a consecutive sample, with no control group. Inpatient and outpatient pediatric rehabilitation center. Adolescents who demonstrated pragmatic deficits and scored a rating of 3 or less on each subdomain of the Rehabilitation Institute of Chicago Rating Scale of Pragmatic Communication Skills (RICE-RSPCS) were eligible for the study. Eight subjects were recruited into the study, and two subjects were lost to follow-up. Thus, six of the eight completed the study. RICE-RSPCS, Communication Performance Scale (CPS). Results: Clinically relevant and statistically significant (P <.01) changes occurred during the treatment and were maintained at follow-up for the four RICE-RSPCS subscales and the CPS. These results suggest that the potential and often typical long-term pragmatic and subsequent social difficulties associated with ABI can possibly be lessened through effective intervention.
Top-cited authors
Marlena M Wald
Jeffrey Kreutzer
  • Virginia Commonwealth University
Wayne A Gordon
  • Icahn School of Medicine at Mount Sinai
John D Corrigan
  • The Ohio State University
Keith D Cicerone
  • JFK Medical Center