Marie N. Dahdah

Comparative effectiveness of traumatic brain injury rehabilitation: Differential outcomes across TBI Model Systems Centers

Objective:To measure patient functional outcomes across rehabilitation centers. Setting:Traumatic Brain Injury Model System (TBIMS) centers. Participants:Patients with traumatic brain injury (TBI) admitted to 21 TBIMS rehabilitation centers (N = 6975, during 1999-2008). Design:Retrospective analysis of prospectively collected data. Main Measures:Center-specific functional outcomes of TBI patients using Functional Independence Measure, Disability Rating Scale, and Glasgow Outcome Scale–Extended. Results:There were large differences in patient characteristics across centers (demographics, TBI severity, and functional deficits at admission to rehabilitation). However, even after taking those factors into account, there were significant differences in functional outcomes of patients treated at different TBIMS centers. Conclusion:There are significant differences in functional outcomes of TBI patients across rehabilitation centers.

Long-term outcomes after moderate-to-severe traumatic brain injury among military veterans: Successes and challenges

Abstract Objective: To assess long-term outcomes after traumatic brain injury (TBI) among veterans and service members. Setting: Regional Veterans Affairs medical centre. Participants: One hundred and eighteen veterans and military personnel, aged 23–70 years (median = 35 years), 90% male, had moderate-to-severe TBI (82% in coma > 1 day, 85% amnesic > 7 days), followed by acute interdisciplinary rehabilitation 5–16 years ago (median = 8 years). Design: Cross-sectional analysis of live interviews conducted via telephone. Main measures: TBI follow-up interview (occupational, social, cognitive, neurologic and psychiatric ratings), Community Integration Questionnaire, Disability Rating Scale (four indices of independent function) and Satisfaction with Life Scale. Results: At follow-up, 52% of participants were working or attending school; 34% ended or began marriages after TBI, but the overall proportion married changed little. Finally, 22% were still moderately-to-severely disabled. However, 62% of participants judged themselves to be as satisfied or more satisfied with life than before injury. Injury severity, especially post-traumatic amnesia, was correlated with poorer outcomes in all functional domains. Conclusions: After moderate–severe TBI, most veterans assume productive roles and are satisfied with life. However, widespread difficulties and functional limitations persist. These findings suggest that veteran and military healthcare systems should continue periodic, comprehensive follow-up evaluations long after moderate-to-severe TBI.

Variations in Inpatient Rehabilitation Functional Outcomes Across Centers in the Traumatic Brain Injury Model Systems Study and the Influence of Demographics and Injury Severity on Patient Outcomes

OBJECTIVE To compare patient functional outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers using an enhanced statistical model and to determine factors that influence those outcomes. DESIGN Multicenter observational cohort study. SETTING TBIMS centers. PARTICIPANTS Patients with traumatic brain injury (TBI) admitted to 19 TBIMS rehabilitation centers from 2003-2012 (N=5505). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Functional outcomes of patients with TBI. RESULTS Individuals with lower functional status at the time of admission, longer duration of posttraumatic amnesia, and higher burden of medical comorbidities continued to have worse functional outcomes at discharge from inpatient rehabilitation and at the 1-year follow-up, whereas those who were employed at the time of injury had better outcomes at both time periods. Risk-adjusted patient functional outcomes for patients in most TBIMS centers were consistent with previous research. However, there were wide performance differences for a few centers even after using more recently collected data, improving on the regression models by adding predictors known to influence functional outcomes, and using bootstrapping to eliminate confounds. CONCLUSIONS Specific patient, injury, and clinical factors are associated with differences in functional outcomes within and across TBIMS rehabilitation centers. However, these factors did not explain all the variance in patient outcomes, suggesting a role of some other predictors that remain unknown.

Coping and adaptive strategies of traumatic brain injury survivors and primary caregivers.

BACKGROUND Qualitative research methods allowed the investigator to contribute to the development of new theories and to examine change in processes over time, which added rich detail to existing knowledge of the use of coping and adaptive strategies by traumatic brain injury survivors and their primary caregivers (Ponsford, Sloan, & Snow, 2013). The advantages of phenomenological study were that it allows flexibility to explore and understand meanings attached by people to well-studied concepts such as coping, resiliency, and adaptation or compensation. Phenomenological study was sensitive to contextual factors. It also permitted the study of in-depth dynamics of coping and adaptive strategies of TBI survivors and primary caregivers, while understanding the social and psychological implications of the phenomenon. OBJECTIVE To explore the needs and deficits of adult traumatic brain injury (TBI) survivors and primary caregivers; and to identify their self-initiated coping and adaptive strategies. Significant to this study was the development of coping and adaptive strategies by the participants after their discharge from inpatient and rehabilitation treatment. The compensatory skills taught in treatment settings did not transfer to the home environment. Therefore, these strategies developed independently from previous treatment recommendations contributed to the development of theory related to rehabilitation and counseling. Distinctive to this study was the similarity of coping and adaptive strategies developed from both mild and severe traumatic brain injury survivors. METHODS This study consisted of eleven with TBI and six primary caregivers (N = 17), who participated in a series of semi-structured interviews aimed at discovering the coping and adaptive strategies utilized in dealing with the effects of brain injury. A Qualitative Phenomenological design was employed. RESULTS Patience and understanding, support, and professional help were identified by TBI survivors and caregivers as being their most relevant needs. Self-reported deficits included short-term memory loss (STM), fatigue, anger, and personality changes, and the strategies that TBI survivors and caregivers identified tended to address their problems with these specific day-to-day deficits. Problem focused, emotion focused, and avoidant coping were utilized to some degree in their adjustment to home life and activities of daily living. Participants offered suggestions for mental health professionals addressing how to more effectively work with brain injury survivors and their primary caregivers. CONCLUSION TBI survivors and caregivers had multiple self-reported unaddressed needs following their discharge from facility-based treatment. They reported spontaneously engaging in various coping and adaptive strategies to address their needs and deficits. However, further education regarding potential post-TBI challenges and strategies for addressing them are needed, including a need for community and mental health resources.

Epidemiology of Comorbid Conditions Among Adults 50 Years and Older With Traumatic Brain Injury

Objectives: Aging individuals with traumatic brain injury (TBI) experience multiple comorbidities that can affect recovery from injury. The objective of this study was to describe the most commonly co-occurring comorbid conditions among adults 50 years and older with TBI. Setting: Level I Trauma centers. Participants: Adults 50 years and older with moderate/severe TBI enrolled in the TBI-Model Systems (TBI-MS) from 2007 to 2014 (n = 2134). Design: A TBI-MS prospective cohort study. Main Measures: International Classification of Disease–9th Revision codes collapsed into 45 comorbidity categories. Comorbidity prevalence estimates and trend analyses were conducted by age strata (50-54, 55-64, 65-74, 75-84, ≥85 years). A dimension reduction method, Treelet Transform, classified clusters of comorbidities that tended to co-occur. Results: The 3 most commonly occurring comorbid categories were hypertensive disease (52.6/100 persons), other diseases of the respiratory system (51.8/100 persons), and fluid component imbalances (43.7/100 persons). Treelet Transform classified 3 clusters of comorbid codes, broadly classified as (1) acute medical diseases/infections, (2) chronic conditions, and (3) substance abuse disorders. Conclusion: This study provides valuable insight into comorbid conditions that co-occur among adults 50 years and older with TBI and provides a foundation for future studies to explore how specific comorbidities affect TBI recovery.

Application of virtual environments in a multi-disciplinary day neurorehabilitation program to improve executive functioning using the Stroop task

BACKGROUND Virtual reality (VR) technology has demonstrated usefulness in diagnosis, education, and training. Studies supporting use of VR as a therapeutic treatment in medical rehabilitation settings remain limited. This study examines the use of VR in a treatment capacity, and whether it can be effectively integrated into neurorehabilitation. OBJECTIVE To determine whether immersive VR treatment interventions improve executive dysfunction in patients with brain injury and whether performance is stronger on a VR version of the Stroop than traditional Stroop formats. METHODS 15 patients with brain injury admitted to day neurorehabilitation. OUTCOME MEASURES reaction time, inhibition, and accuracy indices on VR Stroop; Automated Neuropsychological Assessment Metrics (ANAM) Stroop, Delis-Kaplan Executive Function System Stroop, Golden Stroop, and Woodcock-Johnson, 3rd Edition (WJ-III): Pair Cancellation. RESULTS Participants demonstrated significantly reduced response time on the word-reading condition of VR Stroop and non-significantly reduced response time on the interference condition. Non-significant improvements in accuracy and inhibition were demonstrated on the color-naming condition of VR Stroop. Significantly improved accuracy under time pressure was found for the ANAM, after VR intervention. CONCLUSION Implementation of immersive VR interventions during neurorehabilitation is effective in improving specific executive functions and information processing speed in brain-injured patients during the subacute period.

Service needs and barriers to care five or more years after moderate to severe TBI among Veterans

ABSTRACT Primary objective: The objective of this paper is to identify the most frequent service needs, factors associated with needs, and barriers to care among Veterans and service members five or more years after moderate to severe traumatic brain injury (TBI). Research design: Survey administered via telephone 5–16 years after injury (median eight years) and subsequent acute inpatient rehabilitation at a regional Veterans Affairs (VA) medical centre. Methods and procedures: Participants were 119 Veterans and military personnel, aged 23–70 (median 35), 90% male. Demographics, injury characteristics, service needs, whether needs were addressed, barriers to care, health and general functioning were assessed. Main outcomes and results: The most frequent needs were for help with memory, information about available services and managing stress. Obtaining information about services was the most consistently un-addressed need; managing stress was the most consistently addressed need. Cognitive and psychiatric symptoms and alienation from community were associated with needs going un-addressed. Participants treated after an expansion of TBI services at the study site reported fewer un-addressed needs. Not knowing where to get help was the most common barrier to care. Conclusion: Repeated outreach, assessment of needs and education about available services are needed throughout Veterans’ lifespan after moderate to severe TBI.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

BackgroundAttempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.MethodsA multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.ResultsDraft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.ConclusionEvidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

Functional recovery from neuroinvasive West Nile Virus: A tale of two courses.

OBJECTIVE In 2012, the highest numbers of West Nile Virus (WNV) cases were reported by the Center for Disease Control since 2003. This outbreak included over half of the identified patients being classified with one of the more debilitating neuroinvasive subtypes of WNV. Despite improvements in diagnosis and treatment options in symptom management, longitudinal research on WNV neurocognitive and functional outcomes is limited by sample size, retrospective review, and/or reliance on self-report measures for cognitive status and level of independence. This study describes the cases of 2 patients diagnosed with WNV as they complete rehabilitation across the continuum of care. RESEARCH METHOD Review of two cases that experience different rehabilitation outcomes 4-18 months post diagnosis. RESULTS The cases presented here demonstrate the potentially differential courses of recovery and outcomes for physical (e.g., balance, ambulation, upper extremity function), cognitive (e.g., attention, executive functions, memory, language, visuospatial), and emotional functioning, as assessed via measures administered by the patients physical therapists and neuropsychologists. These patients were evaluated as part of the standard clinical practice to monitor changes, track recovery, and provide recommendations across the continuum of care from admission to discharge from acute inpatient rehabilitation, during outpatient day neurorehabilitation, and while receiving outpatient neuropsychology services. CONCLUSIONS These cases highlight the variability in rehabilitative course for individuals diagnosed with WNV. Consistent follow-up with patients is recommended to ensure management of remitting and chronic symptoms.

Factors associated with rehabilitation outcomes after traumatic brain injury: Comparing functional outcomes between TBIMS centers using hierarchical linear modeling

Objective:To examine differences in patient outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers and factors that influence these differences using hierarchical linear modeling (HLM). Setting:Sixteen TBIMS centers. Participants:A total of 2056 individuals 16 years or older with moderate to severe traumatic brain injury (TBI) who received inpatient rehabilitation. Design:Multicenter observational cohort study using HLM to analyze prospectively collected data. Main Outcome Measures:Functional Independence Measure and Disability Rating Scale total scores at discharge and 1 year post-TBI. Results:Duration of posttraumatic amnesia (PTA) demonstrated a significant inverse relationship with functional outcomes. However, the magnitude of this relationship (change in functional status for each additional day in PTA) varied among centers. Functional status at discharge from rehabilitation and at 1 year post-TBI could be predicted using the slope and intercept of each TBIMS center for the duration of PTA, by comparing it against the average slope and intercept. Conclusions:HLM demonstrated center effect due to variability in the relationship between PTA and functional outcomes of patients. This variability is not accounted for in traditional linear regression modeling. Future studies examining variations in patient outcomes between centers should utilize HLM to measure the impact of additional factors that influence patient rehabilitation functional outcomes.