Jeffrey S. Kreutzer

Assessment of community integration following rehabilitation for traumatic brain injury

Community integration is defined as integration into a home-like setting, integration into a social network, and integration into productive activities such as employment, school, or volunteer work. For the purpose of evaluating outcomes for individuals with traumatic brain injury (TBI) who are prov

The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination

Primary objective: Differing definitions of depression, limited sample sizes, and variability in methodologies have contributed to equivocal findings about the prevalence of depression among persons with traumatic brain injury. The present investigation used standardized diagnostic criteria and a large sample to identify the manifestations of depression after TBI. Methods and procedures: 722 outpatients with brain injury, referred for comprehensive assessment at a regional Level I trauma centre, were studied. Depressive symptoms were characterized utilizing standard DSM-IV criteria and the Neurobehavioural Functioning Inventory. Results: Forty-two per cent of patients with brain injury met the prerequisite number of symptoms for a DSM-IV diagnosis of major depressive disorder. Fatigue (46%), frustration (41%), and poor concentration (38%) were the most commonly cited manifestations of depression. Conclusions: Many patients with brain injury are at great risk for developing depressive disorders. Future res...

Long-term Neuropsychological Outcome After Traumatic Brain Injury

Objective:To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. Design:Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. Setting:National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. Participants:One hundred eighty-two persons with complicated mild to severe traumatic brain injury. Primary Outcome Measures:Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. Results:Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. Conclusions:Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Etiology and incidence of rehospitalization after traumatic brain injury: A multicenter analysis

OBJECTIVE To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury. DESIGN Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. SETTING Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996. MAIN OUTCOME MEASURES Annual incidence and etiology of rehospitalization. RESULTS The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05). CONCLUSIONS There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Primary caregivers' psychological status and family functioning after traumatic brain injury.

This study investigated the prevalence of psychological distress and unhealthy family functioning among primary caregivers of 62 adult outpatients with traumatic brain injury, using the Brief Symptom Inventory (BSI) and the Family Assessment Device (FAD). Approximately half of the caregivers reported elevated distress as indicated by scores on the BSI General Stress Index. Elevations on the Anxiety scale were evident among one-third of the sample, and one-fourth demonstrated elevations on the Depression subscale. Elevated scores on the Paranoid Ideation and Psychoticism scales suggested that feelings of burden and alienation were commonly reported. As indicated by the FAD, caregivers showed greater levels of unhealthy functioning relative to published norms for non-patient and medical patient samples, but showed better functioning than psychiatric samples. Spouses were significantly more likely to report elevated depression scores compared to parents. There was also a trend for spouses to report greater unhealthy family functioning than parents. Findings are consistent with those reported by European researchers. Experience indicates that the BSI and FAD are potentially valuable clinical and research tools.

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis.

OBJECTIVE To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients. DESIGN Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results. SETTING Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS Patients were selected from a national database of 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up. MAIN OUTCOME MEASURE Return to work at 1-year follow-up. RESULTS Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts. CONCLUSIONS Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patients ability to return to work, as well as an operational definition for successful employment.

Moderating factors in return to work and job stability after traumatic brain injury

Objective:To examine job stability moderating variables and develop a postinjury work stability prediction model. Design:Multicenter analysis of individuals with traumatic brain injury (TBI) who returned for follow-up at 1, 2, and 3, or 4 years postinjury, were of working age (between 18 and 62 years of age at injury), and were working preinjury. Setting:Six National Institute on Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. Participants:A total of 186 adults with TBI were included in the study. Main outcome measures:Job stability was categorized as stably employed (employed at all 3 follow-up intervals); unstably employed (employed at one or two of all three follow-up intervals); and unemployed (unemployed at all three follow-up intervals). Results:After injury, 34% were stably employed, 27% were unstably employed, and 39% were unemployed at all three follow-up intervals. Minority group members, people who did not complete high school, and unmarried people were more likely to be unemployed. Driving independence was highly influential and significantly related to employment stability. A discriminant function analysis, which included age, length of unconsciousness and Disability Rating Scale scores at 1 year postinjury, accurately predicted job stability groupings. ConclusionData analysis provided evidence that employment stability is predictable with a combination of functional, demographic, and injury severity variables. Identification of people at risk for poor employment outcomes early on can facilitate rehabilitation planning and intervention.

Predictors of outcome following severe head trauma: follow-up data from the traumatic coma data bank

Outcome as a function of employment status or return to school was evaluated in severely head-injured patients. A priori we selected the most salient demographic, physiological, neuropsychological and psychosocial outcome predictors with the aim of identifying which of there variables captured at baseline or 6 months would best predict employability at 6 or 12 months. Based on the patients evaluated at 6 months, 18% of former workers had returned to gainful employment and 62% of former students had returned to school. For those not back to work or school at 6 months, 31% of the former workers and 66% of the former students had returned by 12 months. Age, length of coma, speed for both attending and motor movements, spatial integration, and intact vocabulary were all significantly related to returning to work or school. The three most potent predictors for returning to work or school were intactness of the patients verbal intellectual power, speed of information processing and age.

Functional measures after traumatic brain injury : ceiling effects of FIM, FIM+FAM, DRS, and CIQ.

Objective:The characteristics of the Disability Rating Scale (DRS), Functional Independence Measure (FIM), Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and Community Integration Questionnaire (CIQ) are examined, especially in regard to a “celling effect” after rehabilitation discharge (ie, how well each of the instruments detects meaningful change in level of function). Design:Data were collected prospectively at admission and discharge from acute inpatient rehabilitation and at years 1 and 2 after injury (the CIQ was collected only at years 1 and 2). Analyses are reported on a subsamplc of cases with listwise deletion, although the analyses were also done using all data available, and results compared to ensure stability of findings between samples. Setting:National database of the four Traumatic Brain Injury (TBI) Model Systems in San Jose, Calif; Detroit, Mich; Richmond, Va; and Houston, Tex. Patients:All consenting patients with TBI age 16 and older admitted to a Model System within 24 hours of Injury and receiving inpatient rehabilitation within the Model System qualified for the study. Data on 612 individuals were collected, with a minimum of 80 cases having complete data over time. Main Outcome Measures:The DRS, FIM, FIM+FAM, and CIQ. Results:There is a substantial ceiling effect of the FIM, even by inpatient rehabilitation discharge (ie, one half of the cases have an average score of 6 to 7 [“independent or modified independence—no helper] across the 18 FIM Items). The FIM+FAM shows a ceiling effect In one third of the cases. The DRS shows less ceiling effect at discharge, 1 year, and 2 years than the FIM or the FIM+FAM. CIQ scores have a ceiling effect on home and social integration subscales when compared with scores from a sample of individuals without disabilities. The productivity subscale remains well below the norm. Conclusions:Celling effects for the FIM, FIM+FAM, and two of the three CIQ subscales indicate that these measures are not as sensitive to changes, especially in the community, as may be needed to assess progress in areas most commonly causing dysfunction for the TBI population. More emphasis must be placed on improved measurement of relevant goals in the postacute and home settings with brief and precise scales

Patient correlates of caregivers' distress and family functioning after traumatic brain injury

This study examined the relationship of patient variables to caregiver distress and family functioning after TBI in 62 families. An extension of Kreutzer et al. 1994 (in press), the present investigation used four categories of predictor variables: indices of injury severity, neuropsychological tests, neurobehavioural problem checklist scales, and kinship of caregiver (i.e. spouse vs. parent). Caregiver distress and family functioning were measured by the Brief Symptom Inventory (BSI) and Family Assessment Device (FAD), respectively. Regression analyses revealed that indices of injury severity did not predict BSI scores. Time post-injury predicted several FAD subscales. The number of the patients neurobehavioural problems predicted BSI subscale scores most consistently, particularly the Global Severity Index, Somatic, Obsessive-Compulsive and Depression scales. Scores on the behaviour problem subscale predicted BSI scores better than other kinds of problems, and also had some relation to several FAD subscales. Of the 10 neuropsychological test scores, those which measured verbal abilities were more predictive of caregivers BSI scores. Kinship (i.e. being a spouse) predicted Depression scores, even when other variables were partialled out. Research findings are integrated with European studies and clinical implications for understanding caregiver distress are discussed.