Head Trauma Rehabilitation

Estimated Life-Time Savings in the Cost of Ongoing Care Following Specialist Rehabilitation for Severe Traumatic Brain Injury in the United Kingdom Objectives: To evaluate cost-efficiency of rehabilitation following severe traumatic brain injury (TBI) and estimate the life-time savings in costs of care. Setting/Participants: TBI patients (n = 3578/6043) admitted to all 75 specialist rehabilitation services in England 2010–2018. Design: A multicenter cohort analysis of prospectively collated clinical data from the UK Rehabilitation Outcomes Collaborative national clinical database. Main Measures: Primary outcomes: (a) reduction in dependency (UK Functional Assessment Measure), (b) cost-efficiency, measured in time taken to offset rehabilitation costs by savings in costs of ongoing care estimated by the Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA), and (c) estimated life-time savings. Results: The mean age was 49 years (74% males). Including patients who remained in persistent vegetative state on discharge, the mean episode cost of rehabilitation was £42 894 (95% CI: £41 512, £44 235), which was offset within 18.2 months by NPCNA-estimated savings in ongoing care costs. The mean period life expectancy adjusted for TBI severity was 21.6 years, giving mean net life-time savings in care costs of £679 776/patient (95% CI: £635 972, £722 786). Conclusions: Specialist rehabilitation proved highly cost-efficient for severely disabled patients with TBI, despite their reduced life-span, potentially generating over £4 billion savings in the cost of ongoing care for this 8-year national cohort.

Strengthening the Evidence Base: Recommendations for Future Research Identified Through the Development of CDC's Pediatric Mild TBI Guideline Objective: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting. Results: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions. Conclusion: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury: Examining Associations With Demographics, Healthcare Utilization, Institutionalization, and 1-Year Outcomes Objectives: To assess the relationship of acute complications, preexisting chronic diseases, and substance abuse with clinical and functional outcomes among adults 50 years and older with moderate-to-severe traumatic brain injury (TBI). Design: Prospective cohort study. Participants: Adults 50 years and older with moderate-to-severe TBI (n = 2134). Measures: Clusters of comorbid health conditions empirically derived from non-injury International Classification of Diseases, Ninth Revision codes, demographic/injury variables, and outcome (acute and rehabilitation length of stay [LOS], Functional Independence Measure efficiency, posttraumatic amnesia [PTA] duration, institutionalization, rehospitalization, and Glasgow Outcome Scale–Extended (GOS-E) at 1 year). Results: Individuals with greater acute hospital complication burden were more often middle-aged men, injured in motor vehicle accidents, and had longer LOS and PTA. These same individuals experienced higher rates of 1-year rehospitalization and greater odds of unfavorable GOS-E scores at 1 year. Those with greater chronic disease burden were more likely to be rehospitalized at 1 year. Individuals with more substance abuse burden were most often younger (eg, middle adulthood), black race, less educated, injured via motor vehicle accidents, and had an increased risk for institutionalization. Conclusion: Preexisting health conditions and acute complications contribute to TBI outcomes. This work provides a foundation to explore effects of comorbidity prevention and management on TBI recovery in older adults.

The Contribution of Social Support, Professional Support, and Financial Hardship to Family Caregiver Life Satisfaction After Traumatic Brain Injury Objectives: (a) To assess whether 3 changeable environmental variables (social support, professional support, and financial hardship) contribute to explaining differences in well-being of family caregivers after traumatic brain injury (TBI), above and beyond the influence of neurobehavioral functioning. (b) To assess the unique and relative contribution of social support, professional support, and financial hardship to life satisfaction of family caregivers. Participants: Adult family caregivers (n = 136) of individuals who received inpatient rehabilitation following a TBI. Measures: The Social Provisions Scale; Brief Scale of Financial Hardship after Brain Injury; Satisfaction with Life Scale; and adapted scales measuring professional support and neurobehavioral functioning. Design: Cross-sectional study using survey methodology. Results: Social support, professional support, and financial hardship explained a significant amount of variance in life satisfaction after controlling for neurobehavioral functioning (R2 change = 0.34, considered a large effect size). Social support and financial hardship were significant unique predictors within the model, but professional support was not. Conclusion: Social support and financial hardship are prominent environmental variables that may hold promise for targeted intervention development and testing designed to support family adaptation after TBI.

A Systematic Review of Sleep-Wake Disturbances in Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life Objective: To systematically appraise the literature on the prevalence, types, and predictors of sleep-wake disturbances (SWD), and on the relationship between SWD, fatigue, depression, and quality of life in children and adolescents with traumatic brain injury (TBI). Methods: MEDLINE, PubMed, PsychInfo, Web of Science, and EMBASE databases were searched, reference lists of retrieved articles were also searched for relevant articles, and study methods were evaluated for risk of bias. Results: Of the 620 articles assessed, 16 met inclusion criteria. Sleep-wake disturbances were common in childhood TBI. The most common types of SWD reported were insomnia and excessive daytime sleepiness, with mild TBI participants showing a trend toward more sleep maintenance insomnia, while sleep-onset insomnia was typical in those with moderate-severe TBI. Predictors of SWD reported in studies involving mild TBI participants included TBI severity, male sex, preexisting SWD, high body weight, and depression; while injury severity and internalizing problems were associated with SWD in moderate-severe TBI participants. Sleep-wake disturbances were also associated with fatigue and poor quality of life following TBI. Conclusion: Sleep-wake disturbances are highly prevalent in childhood TBI, regardless of injury severity. Routine assessments of SWD in survivors of childhood TBI are recommended.

Healthcare Utilization and Missed Workdays for Parents of Children With Traumatic Brain Injury Background: We enrolled patients in a prospective study in which we obtained estimates of the direct and indirect burden for families of children with traumatic brain injury (TBI) relative to a control group of families of children with orthopedic injury (OI). Methods: Parents were surveyed at 3 time points following injury: 3, 6, and 12 months. At each follow-up contact, we asked parents to list the number of workdays missed, number of miles traveled, amount of travel-related costs, and whether their child had an emergency department (ED) visit, hospital admission, any over-the-counter (OTC) medications, and any prescription medications during that time period. We assessed the difference in these outcomes between the TBI and OI groups using multivariable logistic and 2-part regression models to account for high concentrations of zero values. Results: Children with TBI had significantly greater odds of having an ED visit (3.04; 95% CI, 1.12-8.24), OTC medications (1.98; 95% CI, 1.34-2.94), and prescription medications (2.34; 95% CI, 1.19-4.59) than those with OI. In addition, parents of children with TBI missed significantly more days of work (19.91 days; 95% CI, 11.64-28.17) overall during the 12 months following injury than their OI counterparts. Conclusion: Extrapolating our results to the entire country, we estimate that pediatric TBI is associated with more than 670 000 lost workdays annually over the 12 months following injury, which translates into more than $150 million in lost productivity. These missed workdays and lost productivity may be prevented through safety efforts to reduce pediatric TBI.

Protocol for a Randomized Controlled Trial of CI Therapy for Rehabilitation of Upper Extremity Motor Deficit: The Bringing Rehabilitation to American Veterans Everywhere Project Constraint-induced movement therapy (CI therapy) has been shown to reduce disability for individuals with upper extremity (UE) hemiparesis following different neurologic injuries. This article describes the study design and methodological considerations of the Bringing Rehabilitation to American Veterans Everywhere (BRAVE) Project, a randomized controlled trial of CI therapy to improve the motor deficit of participants with chronic and subacute traumatic brain injury. Our CI therapy protocol comprises 4 major components: (1) intensive training of the more-affected UE for target of 3 hour/day for 10 consecutive weekdays, (2) a behavioral technique termed shaping during training, (3) a "transfer package," 0.5 hour/day, of behavioral techniques to transfer therapeutic gains from the treatment setting to the life situation, and (4) prolonged restraint of use of the UE not being trained. The primary endpoint is posttreatment change on the Motor Activity Log, which assesses the use of the more-affected arm outside the laboratory in everyday life situations. Data from a number of secondary outcome measures are also being collected and can be categorized as physical, genomic, biologic, fitness, cognitive/behavioral, quality of life, and neuroimaging measures.

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury Objective: To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation. Design: Retrospective cohort. Setting: Six TBI Model Systems (TBIMS) centers. Participants: In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior. Interventions: Not applicable. Main Outcome Measure: Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity. Results: At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders. Conclusions: People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury Objective: To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI). Setting: Pediatric trauma center ED. Participants: Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting. Design: Thirty-day longitudinal cohort study. Main Measures: Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury. Results: Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up. Conclusions: The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.

Performance Validity in Collegiate Football Athletes at Baseline Neurocognitive Testing Objective: To assess the prevalence of invalid performance on baseline neurocognitive testing using embedded measures within computerized tests and individually administered neuropsychological measures, and to examine the influence of incentive status and performance validity on neuropsychological test scores. Setting: Sport-related concussion management program at a regionally accredited university. Participants: A total of 83 collegiate football athletes completing their preseason baseline assessment within the University's concussion management program and a control group of 140 nonathlete students. Design: Cross-sectional design based on differential incentive status: motivated to do poorly to return to play more quickly after sustaining a concussion (athletes) versus motivated to do well due to incentivizing performance (students). Main Measures: Immediate Post-Concussion and Cognitive Testing (ImPACT), performance validity tests, and measures of cognitive ability. Results: Half of the athletes failed at least 1 embedded validity indicator within ImPACT (51.8%), and the traditional neuropsychological tests (49.4%), with large effects for performance validity on cognitive test scores (d: 0.62-1.35), incentive status (athletes vs students; d: 0.36-1.15), and the combination of both factors (d: 1.07-2.20) on measures of attention and processing speed. Conclusion: Invalid performance on baseline assessment is common (50%), consistent across instruments (ImPACT or neuropsychological tests) and settings (one-on-one or group administration), increases as a function of incentive status (risk ratios: 1.3-4.0) and results in gross underestimates of the athletes' true ability level, complicating the clinical interpretation of the postinjury evaluation and potentially leading to premature return to play.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com