Robin A. Hanks

Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress.

Objective:This study examined predictors of family dysfunction and caregiver distress among 60 pairs of persons who sustained a traumatic brain injury and their caregivers. Design:A cross-sectional design that used hierarchical multiple regression analyses evaluated the relative influences of time since injury, awareness of deficit, and neurobehavioral and neuropsychological functioning of the person with injury, and caregiver perceived social support. Results:The predictor model accounted for 52% of the variance in family dysfunction and 39% in caregiver psychological distress. Neurobehavioral disturbance in the person with injury was the strongest predictor of caregiver distress. Social support showed a direct and linear relationship to family functioning, and it was the strongest predictor of family functioning. Social support was a powerful moderator of caregiver psychological distress. In the absence of adequate social support, caregiver distress increased with longer time after injury, cognitive dysfunction, and unawareness of deficit in care recipients, whereas these characteristics were not associated with distress among caregivers with adequate social support. Conclusions:Rehabilitation professionals should stress the importance of caregivers and families of persons with TBI seeking and obtaining adequate social support.

Neuropsychologic and Functional Outcome After Complicated Mild Traumatic Brain Injury

OBJECTIVE To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery. DESIGN A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury. SETTING Rehabilitation hospital with a Traumatic Brain Injury Model System. PARTICIPANTS Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design. RESULTS Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up. CONCLUSIONS When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.

Measures of executive functioning as predictors of functional ability and social integration in a rehabilitation sample

OBJECTIVE To examine the utility of executive function tests in predicting rehabilitation outcome. DESIGN A prospective, descriptive study of the value of neuropsychologic and motor functioning measures in the prediction of functional outcome 6 months after acute rehabilitation. SETTING A Midwestern, urban, university-affiliated rehabilitation hospital. PATIENTS Ninety consecutive admissions to traumatic brain injury, orthopedic, and spinal cord injury units. Age of the participants ranged from 17 to 73. MAIN OUTCOME MEASURES Community Integration Questionnaire (CIQ), Disability Rating Scale (DRS), SF-36 Health Survey. RESULTS Canonical correlation analyses indicated that measures of executive functioning and verbal memory were strongly related to measures of functional outcome 6 months after rehabilitation, as measured by the DRS and the CIQ. In contrast, perceived health status as measured by the SF-36 was highly related to estimated premorbid IQ and modestly related to visuospatial impairment. CONCLUSIONS Executive functioning, verbal memory, and estimated premorbid intelligence predict functional dependence after discharge from rehabilitation beyond information regarding basic sensory and motor skills. Moreover, there is a dissociation between measures of functional outcome, such that objective and behaviorally oriented measures of disability (CIQ and DRS) are strongly related to each other; however, they are not related to perceptions of general health status (SF-36).

Executive functioning and predictors of falls in the rehabilitation setting.

OBJECTIVE To examine the incremental utility of executive function tests in the prediction of inpatient falls. DESIGN Evaluation of neuropsychologic and medical risk factors for fall was completed at admission. Inpatient falls were tabulated following discharge. SETTING A freestanding, urban rehabilitation hospital. PATIENTS Ninety consecutive admissions to traumatic brain injury, orthopedic, and spinal cord injury wards. Age of the participants ranged from 17 to 73 years old. MAIN OUTCOME MEASURE Incident reports of inpatient falls. RESULTS Standard multiple regression analyses indicated that measures of executive functioning sensitive to self-monitoring accounted for unique variance in falls beyond that explained by age and functional motor ability as assessed by the Functional Independence Measure. Visuospatial functioning, although not directly related to falls, was a significant predictor in combination with measures of executive functioning. Together, these variables accounted for 30.3% of the variance in inpatient falls (multiple r = .55; p < .001). CONCLUSION The findings suggest that the influence of motor and sensory impairments on falls are moderated, in part, by executive functioning. Patients with intact executive functioning are less likely to act in ways that could result in a fall; thus, aggressive fall prevention measures may be unnecessary. In contrast, executive dysfunction may signal the need for intervention, even among patients whose profiles are unremarkable with regard to traditional risk factors for fall.

Neuropsychological performance and sleep disturbance following traumatic brain injury.

ObjectiveTo examine the relation between sleep disturbance and neurocognitive ability among persons with traumatic brain injury (TBI). DesignCorrelational research evaluating demographic and neuropsychological predictors of sleep disturbance using multiple regression analysis and analysis of variance. ParticipantsEighty-seven patients with mild to severe TBI admitted to a comprehensive outpatient neurorehabilitation program. Main Outcome MeasuresSleep disturbance assessed using the Pittsburgh Sleep Quality Index. ResultsHierarchical regression analysis revealed that performance on selected measures of cognitive functioning significantly improved prediction of sleep disturbance, accounting for 14% of variance beyond that accounted for by injury severity and gender. The total model accounted for 31% of the variance in Pittsburgh Sleep Quality Index scores. Patients with mild TBI reported more sleep disturbance (P < .01) than did patients with severe TBI. ConclusionsSleep disturbance among patients with TBI may be associated with a particular constellation of neuropsychological abilities. These issues are discussed in relation to prior findings that indicate the involvement of additional neuropsychiatric factors associated with sleep disturbance in mild TBI.

Life satisfaction after traumatic brain injury and the World Health Organization model of disability.

Pierce CA, Hanks RA: Life satisfaction after traumatic brain injury and the World Health Organization model of disability. Am J Phys Med Rehabil 2006;85:889–898. Objective:To determine which components of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) are most predictive of global life satisfaction after traumatic brain injury (TBI). Design:Prospective evaluation of 180 individuals enrolled in a TBI model system project site. Results:Multiple regression analysis indicated that the combination of ICF components (body function and structure, activities, and participation) and demographic factors significantly predicted life satisfaction and accounted for 17% of the variance. Participation was the strongest predictor; activities were a significant, but weaker predictor; and body function and structure did not add to the prediction of life satisfaction. Of all the individual variables evaluated, only social integration and productivity were found to be significant, unique predictors. Conclusions:When considering the effects of various aspects of disabling conditions on the life satisfaction of individuals who have suffered a TBI, restriction of participation in life activities was found to have the greatest impact. Although the model accounted for a significant percentage in the variation of life satisfaction, a large proportion of the predictive picture (>82%) remains unclear. Doubtless, other variables impinge on life satisfaction that would further clarify the complex relationship between disabling conditions and life satisfaction in TBI.

The Predictive Validity of a Brief Inpatient Neuropsychologic Battery for Persons With Traumatic Brain Injury

OBJECTIVE To examine the predictive validity of a brief neuropsychologic test battery consisting of the Galveston Orientation and Amnesia Test, the California Verbal Learning Test-II, Trail-Making Test (TMT), Symbol Digit Modalities Test, grooved pegboard, phonemic and categorical word generation tasks, the Wechsler Test of Adult Reading (WTAR), and the Wisconsin Card Sorting Test-64 relative to functional outcome at 1 year in persons with traumatic brain injury. DESIGN Inception cohort study. Follow-up period of 12 months. SETTING Seven Traumatic Brain Injury Model System centers. Neuropsychologic testing was conducted during the acute inpatient rehabilitation stay and functional outcome measures were obtained at 1-year outpatient follow-up. PARTICIPANTS Adults (N=174) who met criteria for admission to inpatient brain injury rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM instrument, Disability Rating Scale, Supervision Rating Scale, Satisfaction With Life Scale (SWLS), and Glasgow Outcome Scale-Extended. RESULTS Multiple regression analyses revealed that performance on the neuropsychologic test battery was predictive of outcome at 1 year postinjury for all outcome measures, except FIM motor scores and the SWLS. Cognitive performance using this battery was found to predict 1-year outcomes above and beyond functional variables and injury severity variables collected during inpatient rehabilitation, thereby indicating incremental validity for this test battery. Individual tests that were found to be significant predictors of 1-year outcomes included the WTAR and TMT part B. CONCLUSIONS These findings support the clinical utility and ecological validity of this battery with respect to level of disability, functional independence, and supervision required.

Effort Indicators within the California Verbal Learning Test-II (CVLT-II)

This study determined whether performance patterns on the California Verbal Learning Test-II (CVLT-II) could differentiate participants with traumatic brain injury (TBI) showing adequate effort from those with mild TBI exhibiting poor effort using a case-control design. The TBI group consisted of 124 persons with moderate to severe traumatic brain injury (TBI). The poor effort group consisted of 77 persons with mild head injury who were involved in litigation (LG) and failed at least one stand-alone symptom validity measure (SVT) and also either a second SVT or an effort indicator embedded within a standard clinical test. A total of 18 CVLT-II variables were investigated using Bayesian model averaging (BMA) for logistic regression to determine which variables best differentiated the groups. The CVLT-II variables having the most support were Long-Delay Free Recall, Total Recognition Discriminability (d′), and Total Recall Discriminability.

Social Support Moderates Caregiver Life Satisfaction Following Traumatic Brain Injury

Social support is an important determinant of adjustment following traumatic brain injury (TBI) sustained by a family member. The present study examined the extent to which social support moderates the influence of characteristics of the person with injury on caregiver subjective well-being. Sixty pairs of individuals who had sustained a moderate to severe TBI and their caregivers (N = 120) participated. Years postinjury ranged from 0.3 to 9.9 (M = 4.8, SD = 2.6). Cognitive, functional, and neurobehavioral functioning of participants with TBI were assessed using neuropsychological tests and rating scales. Caregiver life satisfaction and perceived social support were assessed using self-report questionnaires. Results indicated that time since injury was unrelated to life satisfaction. Neurobehavioral disturbances showed an inverse relation with life satisfaction. Social support emerged as an important moderator of life satisfaction. Only among caregivers with low social support was cognitive dysfunction adversely related to life satisfaction. Similarly, a trend suggested that patient unawareness of deficit was associated with caregiver life dissatisfaction only among caregivers with low social support. In contrast, these characteristics were unrelated to life satisfaction among caregivers with adequate social support.

Race and productivity outcome after traumatic brain injury: influence of confounding factors.

Objective:Investigate the impact of race on productivity outcome after traumatic brain injury (TBI) and evaluate the influence of confounding factors on this relationship. Design:Inception cohort of 1083 adults with TBI for whom 1-year productivity follow-up data were available. Results:Univariable logistic regression indicated that race was a significant predictor of productivity outcome after TBI. African Americans were 2.76 times more likely to be nonproductive than whites and other racial minorities were 1.92 times more likely to be nonproductive than whites. Multivariable logistic regression analyses revealed that the effect of race on employability was influenced by confounds with preinjury productivity, education level, and cause of injury. After adjustment for other predictors, African Americans were 2.00 times more likely to be nonproductive than whites and other racial minorities were 2.08 times more likely to be nonproductive than whites. The multivariable logistic regression model with all predictors except race accounted for 39% of the variability in productivity outcome (R2-Nagelkerke = 0.39), whereas the full logistic regression model including race accounted for 41% of the variability in productivity outcome (R2-Nagelkerke = 0.41); a difference of only 2%. Conclusion:Any effect of race on productivity is significantly influenced by confounding with preinjury productivity, education level, and cause of injury.