Mark Sherer

Prediction of employment outcome one to three years following traumatic brain injury (TBI)

The current study investigated the relationship between age, education (EDUC), pre-injury productivity (PIP), Glasgow Coma Scale score, and a functional rating score at admittance and discharge from rehabilitation (Disability Rating Scale [DRS]) to employment status at one to three years following traumatic brain injury. EDUC, admit DRS, discharge DRS, and PIP all correlated significantly with follow-up employment status, 0.29, -0.32, -0.36, and 0.25 respectively. All possible combinations were then evaluated by Mallows Cp statistic. The best fitting model was then used in a discriminant function analysis. The discriminant function correctly classified 84% of the employed subjects, 66% of the unemployed, and 75% across both groups. The current results compare favourably with those obtained in previous studies.

TBI-QOL: Development and Calibration of Item Banks to Measure Patient Reported Outcomes Following Traumatic Brain Injury.

Objective:To use a patient-centered approach or participatory action research design combined with advanced psychometrics to develop a comprehensive patient-reported outcomes (PRO) measurement system specifically for individuals with traumatic brain injury (TBI). This TBI Quality-of-Life (TBI-QOL) measurement system expands the work of other large PRO measurement initiatives, that is, the Patient-Reported Outcomes Measurement Information System and the Neurology Quality-of-Life measurement initiative. Setting:Five TBI Model Systems centers across the United States. Participants:Adults with TBI. Design:Classical and modern test development methodologies were used. Qualitative input was obtained from individuals with TBI, TBI clinicians, and caregivers of individuals with TBI through multiple methods, including focus groups, individual interviews, patient consultation, and cognitive debriefing interviews. Item pools were field tested in a large multisite sample (n = 675) and calibrated using item response theory methods. Main Outcomes Measures:Twenty-two TBI-QOL item banks/scales. Results:The TBI-QOL consists of 20 independent calibrated item banks and 2 uncalibrated scales that measure physical, emotional, cognitive, and social aspects of health-related quality of life. Conclusions:The TBI-QOL measurement system has potential as a common data element in TBI research and to enhance collection of health-related quality-of-life and PRO data in rehabilitation research and clinical settings.

Amantadine Effect on Perceptions of Irritability after Traumatic Brain Injury: Results of the Amantadine Irritability Multisite Study

Abstract This study examines the effect of amantadine on irritability in persons in the post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6 months post-TBI with irritability who were enrolled in a parallel-group, randomized, double-blind, placebo-controlled trial receiving either amantadine 100u2009mg twice daily or equivalent placebo for 60 days. Subjects were assessed at baseline and days 28 (primary end-point) and 60 of treatment using observer-rated and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item (primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between the two groups were not statistically significantly different at day 28 or 60; however, observers rated the majority in both groups as having improved at both intervals. Participant ratings for day 60 demonstrated improvements in both groups with greater improvement in the amantadine group on NPI-I Most Problematic (p<0.04) and NPI-I Distress (p<0.04). These results were not significant with correction for multiple comparisons. CGI demonstrated greater improvement for amantadine than the placebo group (p<0.04). Adverse event occurrence did not differ between the two groups. While observers in both groups reported large improvements, significant group differences were not found for the primary outcome (observer ratings) at either day 28 or 60. This large placebo or nonspecific effect may have masked detection of a treatment effect. The result of this study of amantadine 100u2009mg every morning and noon to reduce irritability was not positive from the observer perspective, although there are indications of improvement at day 60 from the perspective of persons with TBI and clinicians that may warrant further investigation.

Predictive utility of weekly post-traumatic amnesia assessments after brain injury: A multicentre analysis

Primary objective: To consider the duration of post-traumatic amnesia (PTA) as a single predictor variable to determine whether categories of PTA duration exist that predict 1-year outcomes after traumatic brain injury (TBI). Research design: Using the TBI Model System database (n = 5250), the duration of PTA that predicts 1-year outcomes was calculated. Logistic regression was used to determine whether a single predictive threshold value existed. Classification and regression tree analysis then determined whether multiple threshold values existed. The area under the ROC curve and percentage correct classification were also calculated to discriminate classification accuracy and choose the best predictive thresholds. Results: A single threshold value of PTA days was identified for all variables. At 1 year, PTA that extended into week 7 after injury predicted total FIM™ and FIM™ sub-scales. One-year employment and global outcomes were predicted by PTA extending into week 4 after injury. Independent living was predicted by PTA extending into the 8th week after injury. Conclusion: After moderate-to-severe TBI, determining the presence of PTA at weekly intervals can efficiently determine injury severity while providing meaningful precision when used in research and clinical outcome prediction.

Participant-proxy agreement on objective and subjective aspects of societal participation following traumatic brain injury.

Objective:To examine congruence between participant (P) and significant other (SO) reports on societal participation in 3 objective domains (economic, community, and social activities) and subjective satisfaction with participation at 1 year after traumatic brain injury (TBI). Participants:Ninety-seven persons with moderate to severe TBI and their SOs (27 spouses/partners, 47 parents, 23 other relatives/friends). Main outcome measure:Community Participation Indicators questionnaire, divided into Objective (Economic, Community, Social) and Subjective (Satisfaction) subscales. Design:Prospective correlational study. Results:P-SO congruence differed by domain of participation, with Economic and Community indicators showing higher agreement than Social and Satisfaction items. Congruence was not affected by P-SO relationship or whether the pair lived together. However, pairs who spent at least daily time together had significantly higher agreement on Satisfaction items than pairs who were together less often. Congruence was not predicted by SOs self-reported degree of awareness of Ps concerns. Severity of TBI, within the range represented in this sample, had no effect on P-SO congruence in any domain. Conclusion:In research on participation after TBI, proxy report may be an acceptable substitute for missing participant report on productivity and community activity outcomes. However, proxy responses should be used with caution for questions about social activities and degree of satisfaction with participation.

Recommendations From the 2013 Galveston Brain Injury Conference for Implementation of a Chronic Care Model in Brain Injury

Author Affiliations: Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis (Drs Malec and Hammond); Rehabilitation Medicine, New York University School of Medicine and Rusk Institute of Rehabilitation Medicine, NYU-Langone Medical Center, New York (Dr Flanagan); Physical Medicine and Rehabilitation, Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (Dr Kean); TIRR Memorial Hermann and Physical Medicine and Rehabilitation, University of Texas Medical School at Houston, Baylor College of Medicine, Houston (Drs Sander, Sherer); and Transitional Learning Center and University of Texas Medical Branch, Galveston (Dr Masel).

Handbook on the neuropsychology of traumatic brain injury

Part 1:Introduction to Traumatic Brain Injury.- 1.Epidemiology and Societal Impact of Traumatic Brain Injury.- 2.Cognitive and Behavioral Outcomes from Traumatic Brain Injury.- Part 2:Assessment.- 3.Bedside Evaluations.- 4.Comprehensive Assessment.- 5.Outcome Assessment.- 6.Neuroimaging in Traumatic Brain Injury.- Part 3:Intervention.- 7.A Systematic and Evidence-Based Approach to Clinical Management of Patients with Disorders of Consciousness.- 8.Behavioral Assessment of Acute Neurobehavioral Syndromes to Inform Treatment.- 9.Rehabilitation of Memory Problems Associated with Traumatic Brain Injury.- 10.Rehabilitation of Attention and Executive Function Impairments.- 11.Social Communication Interventions.- 12.Impaired Self-awareness.- 13.Emotional Distress Following Traumatic Brain Injury.- 14.Treating and Collaborating With Family Caregivers in the Rehabilitation of Persons with Traumatic Brain Injury.- 15.Comprehensive Brain Injury Rehabilitation in Post-Hospital Treatment Settings.- Part 4:Special Issues.- 16Pediatric Traumatic Brain Injury: Outcome, Assessment, and Intervention.- 17.Assessment and Treatment of Older Adults with Traumatic Brain Injuries.- Part 5:Mild TBI.- 18.Mild Traumatic Brain Injury.- 19.Malingering in Mild Traumatic Brain Injury.- 20.Special Issues with Mild TBI in Veterans and Active Duty Service Members.

Principles and Practice of Lifespan Developmental Neuropsychology: Neurobehavioral aspects of traumatic brain injury sustained in adulthood

Introduction Traumatic brain injury (TBI) is an important public health issue in the USA, with estimates of over 1.5 million new cases a year, most commonly due to motor vehicle accidents and falls [1]. TBI ranges in severity from mild to severe and results in some disturbance in cognitive, behavioral, emotional, or physical functioning. Often the effects of TBI are not physically observable to others, and thus are not well understood or appreciated by the general public. For persons with mild injuries, these effects may be first recognized, diagnosed, and treated by neuropsychologists. Thus, it is imperative that neuropsychologists have a good understanding of the short- and long-term cognitive, neurobehavioral, and psychosocial effects of TBI and how these effects change over the course of TBI recovery. Although no particular demographic group is biologically predisposed to brain injury, certain groups are at higher risk. In adults, rates for TBI peak between the ages of 15 and 24 years and for persons older than 64 [2]. Other than for the very young or the very old, TBI rates are universally higher for men than women [3]. Other risk factors for brain injury include alcohol consumption [4], prior brain injury [5], and low socioeconomic status [6]. TBIs related to sports and recreation activities are receiving more attention, with an estimated 300,000 sports-related injuries with loss of consciousness each year [7].

Application and clinical utility of the Glasgow Coma Scale over time: A study employing the NIDRR traumatic Brain Injury Model Systems database

Objective:To examine possible changes in Glasgow Coma Scale (GCS) scores related to changes in emergency management, such as intubation and chemical paralysis, and the potential impact on outcome prediction. Participants:10 228 patients from the Traumatic Brain Injury Model Systems national database. Design:Retrospective study examining 5-year epochs from 1987 to 2012. Main Measures:GCS score assessed in the Emergency Department (GCS scores for intubated, but not paralyzed, patients were estimated with a formula using 2 of the 3 GCS components), Outcome: Functional Independence Measure (FIM) assessed at rehabilitation admission. Results:The rate of intubation prior to GCS scoring averaged 43% and did not increase across time. However, a clear increase over time was observed in the use of paralytics or heavy sedatives, with 27% of patients receiving this intervention in the most recent epoch. Estimated GCS scores classified 69% of intubated patients as severely brain injured and 8% as mildly injured. The GCS accounted for a modest, yet consistent, amount of variability (approximately 5%-7%) in FIM scores during most epochs. Conclusions:Given the frequency of intubation and/or paralysis following brain injury in this sample, estimating GCS or exploring other means to gauge injury severity is beneficial, particularly because a portion likely did not sustain severe brain injury. There is no evidence for declining predictive utility of the GCS over time.

Comparison of the VA and NIDILRR TBI model system cohorts

Objective:Within the same time frame, compare the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and VA Traumatic Brain Injury Model System (TBIMS) data sets to inform future research and generalizability of findings across cohorts. Setting:Inpatient comprehensive interdisciplinary rehabilitation facilities. Participants:Civilians, Veterans, and active duty service members in the VA (n = 550) and NIDILRR civilian settings (n = 5270) who were enrolled in TBIMS between August 2009 and July 2015. Design:Prospective, longitudinal, multisite study. Main Measures:Demographics, Injury Characteristics, Functional Independence Measures, Disability Rating Scale. Results:VA and NIDILRR TBIMS participants differed on 76% of comparisons (18 Important, 8 Minor), with unique differences shown across traumatic brain injury etiology subgroups. The VA cohort was more educated, more likely to be employed at the time of injury, utilized mental health services premorbidly, and experienced greater traumatic brain injury severity. As expected, acute and rehabilitation lengths of stay were longer in the VA with no differences in death rate found between cohorts. Conclusions:Substantial baseline differences between the NIDILRR and VA TBIMS participants warrant caution when comparing rehabilitation outcomes. A substantive number of NIDILRR enrollees had a history of military service (>13%) warranting further focused study. The TBIMS participant data collected across cohorts can be used to help evidence-informed policy for the civilian and military-related healthcare systems.