David L. Ripley

Predictors for return to work after spinal cord injury: A 3-year multicenter analysis

OBJECTIVE To examine the ability of the Motor Index Score (MIS), in combination with demographic variables, to predict return to work during a 3-year period for individuals with spinal cord injury (SCI). METHODS Prospectively collected data, between 1986 and 1995, submitted to the National Spinal Cord Injury Statistical Center were analyzed to determine the prediction of return to work utilizing variables of education, ethnicity, age, marital status, gender, and MIS. Individuals, aged 18 to 65 yrs, employed at the time of their injury, were evaluated at discharge from rehabilitation and at 1 (YR1), 2 (YR2), and 3 (YR3) years postinjury (sample sizes of 1,857, 1,486, and 1,177, respectively). RESULTS The most important predictors of return to work were education, MIS, ethnicity, and age at onset of SCI. These variables resulted in a high rate of accuracy for predicting across all 3 yrs (YR1, 81%; YR2, 82%; YR3, 77%). CONCLUSIONS The ability to predict return to work after SCI was shown utilizing MIS and demographic variables, with nearly 80% accuracy. This suggests that return to work after SCI is a dynamic process, with the level of importance of each variable changing with time postinjury.

Charges and lengths of stay for acute and inpatient rehabilitation treatment of traumatic brain injury 1990?1996

This investigation evaluated yearly trends in charges and lengths of stay for patients with brain injury in acute care and rehabilitation settings over a 7 year period. Data was collected from 800 consecutive patients enrolled in four NIDRR Model Systems Traumatic Brain Injury programmes. Acute care daily charges showed almost routine increases, averaging nearly

Return to driving within 5 years of moderate-severe traumatic brain injury

550 per year. Conversely, lengths of stay generally showed a downward trend, with annual reductions averaging 2.25 days. Admission lengths of stay averaged 22-29 days between 1990-1994. Admissions averaged less than 20 days beginning in 1995, with the 1996 average of 16 days, nearly half that of the 1993 average. Between 1990-1996, average daily rehabilitation charges increased each year, with the rise averaging

Relationships Among Premorbid Alcohol Use, Acute Intoxication, and Early Functional Status After Traumatic Brain Injury

83 or 7%. The rise in daily rehabilitation charges was offset by corresponding decreases in lengths of stay averaging 3.65 days or 8% annually. Increases in daily charges for brain injury rehabilitation care were roughly comparable to those for general medical care prices. However, the rate of change in acute care charges was substantially greater, with annual increases averaging 10% more than national medical care prices. The steady downward trend in lengths of stay raises serious concerns about the future availability of health care services to persons with brain injury.

Hypogonadism on admission to acute rehabilitation is correlated with lower functional status at admission and discharge

Primary objective: To examine return to driving and variables associated with that activity in a longitudinal database. Research design: Retrospective analysis of a large, national database. Methods and procedures: The sample was comprised of people with predominantly moderate–severe traumatic brain injury (TBI) enrolled in the TBI Model System national database at 16 centres and followed at 1 (n = 5942), 2 (n = 4628) and 5 (n = 2324) years after injury. Main outcomes and results: Respondents were classified as driving or not driving at each follow-up interval. Five years after injury, half the sample had returned to driving. Those with less severe injuries were quicker to return to driving, but, by 5 years, severity was not a factor. Those who were driving expressed a higher life satisfaction. Functional status at rehabilitation discharge, age at injury, race, pre-injury residence, pre-injury employment status and education level were associated with the odds of a person driving. Conclusions: Half of those with a moderate–severe TBI return to driving within 5 years and most of those within 1 year of injury. Driving is associated with increased life satisfaction. There are multiple factors that contribute to return to driving that do not relate to actual driving ability.

Atomoxetine for individuals with traumatic brain injury.

OBJECTIVE To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI). DESIGN Prospective cohort study. SETTING Acute inpatient TBI rehabilitation. PARTICIPANTS Participants were 1748 persons with TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation. RESULTS Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS. CONCLUSIONS The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.

Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: A TBI model systems multicenter study

Primary objective: To investigate the association between hormone levels and functional status during acute TBI rehabilitation. Research design: Retrospective cohort study of 43 men with moderate-to-severe TBI admitted to an acute rehabilitation unit during a 1 year period. Methods and procedures: Labs were drawn on admission, including total and free testosterone (T), prolactin, adrenocorticotropin hormone (ACTH), cortisol, thyroid stimulating hormone (TSH), free thyroxine (fT4) and insulin-like growth factor (IGF-1). Functional Independence Measure (FIM) scores were obtained at admission and discharge. Main outcome and results: Associations between admission hormone levels and the main outcomes, admission and discharge FIM scores, were assessed using linear regression. Lower total and free T-levels at admission were associated with lower total FIM scores at admission (p < 0.038) and discharge (p < 0.046). Higher cortisol levels at admission were significantly associated with lower admission (p = 0.012) and discharge (p = 0.036) scores on the cognitive-FIM. Prolactin, TSH, fT4 and IGF-1 were not correlated with functional status. Conclusions: In men, lower total and free T-levels at admission to acute rehabilitation correlate with lower admission and discharge FIM scores. These data support the need for studies to investigate the impact of physiological testosterone therapy on outcomes during and post-rehabilitation.

Atomoxetine for attention deficits following traumatic brain injury: results from a randomized controlled trial.

A (brand name Strattera)® is a selective norepinephrine reuptake inhibitor currently indicated for attentiondeficit hyperactivity disorder (ADHD). It is the only medicine currently approved by the Food and Drug Administration for the treatment of ADHD in adults.1,2 This medication has gained considerable interest as an alternative medication for treating traumatic brain injury–(TBI) related attentional problems, hypoarousal, initiation disorders, and fatigue. Up to 30% of individuals with attentional disorders do not tolerate or do not respond to treatment with traditional stimulant medications.1 Therefore, a medication that is effective in treating attention disorders, with an alternative mechanism of action, is clearly of interest. In addition, unlike most medications used to treat attentional disorders, atomoxetine is not a Drug Enforcement Agency Schedule II medication and, therefore, is more convenient for physicians and patients, as unique prescriptions are not needed for each month’s dosage, and onceor twicedaily dosing can potentially eliminate the need for dosing during school or work hours. Lastly, in

The impact of diabetes mellitus on stroke acute rehabilitation outcomes.

Objective:To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Community. Participants:A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community. Main Measures:Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9. Results:Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23–5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression. Conclusions and Implications:Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

Vision disturbance after TBI.

Abstract Objective: To determine if atomoxetine would improve attention impairment following traumatic brain injury (TBI). Setting: Outpatients from a free-standing, private, not-for-profit rehabilitation hospital. Population: Fifty-five adult participants with a history of a single moderate-to-severe TBI, who were at least 1 year from injury and with self-reported complaints of attention difficulties. Intervention: Atomoxetine, a selective norepinephrine re-uptake inhibitor with a primary indication for attention dosed at 40 mg twice a day for 2 weeks, compared to placebo. Design: Randomized double-blind placebo controlled trial, with placebo run-in. Measures: Cognitive Drug Research (CDR), Computerized Cognitive Assessment System, Stroop Color and Word Test, Adult ADHD Self-Report Scale (ASRS-v1.1), Neurobehavioural Functioning Inventory (NFI). Results: Atomoxetine was well-tolerated by the subject sample. The use of atomoxetine by individuals with reported attention difficulty following TBI did not significantly improve scores on measures of attention, the CDR Power of Attention domain or the Stroop Interference score. In addition, no significant relationship was found between atomoxetine use and self-reported symptoms of attention or depression. Conclusion: Atomoxetine did not significantly improve performance on measures of attention among individuals post-TBI with difficulties with attention. This study follows a trend of other pharmacological studies not demonstrating significant results among those with a history of TBI. Various possibilities are discussed, including the need for a more sophisticated system of classification of TBI. Trial registration: ClinicalTrials.gov identifier: NCT00702364.