Stephanie A. Kolakowsky-Hayner

Insomnia, fatigue, and sleepiness in the first 2 years after traumatic brain injury: an NIDRR TBI Model System Module study

Objective:To determine the prevalence of insomnia and posttraumatic brain injury (TBI) fatigue (PTBIF) in individuals with moderate to severe TBI, to explore the relationship between PTBIF and insomnia and their association with outcomes. Design:Cross-sectional study. Setting:Five National Institute of Disability and Rehabilitation Research TBI Model Systems. Participants:Three hundred thirty-four individuals with TBI who completed 1-year (n = 213) or 2-year (n = 121) follow-up interviews between 2008 and 2012. Main Outcome Results:Insomnia occurred in 11% to 24% and PTBIF in 33% to 44% of the individuals. Insomnia and fatigue were both related to sleep disturbance, sleep hygiene, satisfaction with life, anxiety, and depression. PTBIF was associated with greater disability and sleepiness. Insomnia without fatigue was rare (2%-3%) but PTBIF without insomnia occurred in 21% to 23% of the individuals. Comorbidity occurred in 9% to 22% of the individuals. Conclusions:Although PTBIF and insomnia are closely related and both associated with poorer quality of life, they are affected independently by a variety of factors, especially psychopathology and sleep quality. A majority of individuals with PTBIF do not have insomnia; and PTBIF appears to be related to disability severity and daytime sleepiness, where insomnia is not. Demographic and injury variables are not strong predictors of insomnia or PTBIF.

Mortality after surviving traumatic brain injury: Risks based on age groups

Objective:To assess mortality, life expectancy, risk factors, and causes of death by age groups among persons who received inpatient traumatic brain injury (TBI) rehabilitation. Design:Prospective cohort study. Setting:The TBI Model Systems. Participants:8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. Interventions:Not applicable. Main Outcome Measures:Standardized mortality ratio, life expectancy, and cause of death. Results:Moderate-severe TBI increases risk of mortality compared with the general population in all age groups, with the exception of those 85 years or older at the time of injury. Teenagers to middle-aged adults are at particular risk. Risk factors for death varied by age group and included gender, marital and employment status, year and cause of injury, and level of disability. External causes of death predominate in younger groups. For the youngest male participants in the sample, longevity was reduced up to 16 years. Conclusion:Risk factors and causes of death varied considerably by age group for individuals with moderate-severe TBI who were receiving acute care rehabilitation. Moderate-severe TBI is a chronic health condition.

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.

Prior history of traumatic brain injury among persons in the Traumatic Brain Injury Model Systems National Database

OBJECTIVE To determine the association between demographic, psychosocial, and injury-related characteristics and traumatic brain injury (TBI) occurring prior to a moderate or severe TBI requiring rehabilitation. DESIGN Secondary data analysis. SETTING TBI Model System inpatient rehabilitation facilities. PARTICIPANTS Persons (N=4464) 1, 2, 5, 10, 15, or 20 years after TBI resulting in participation in the TBI Model System National Database. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES History of TBI prior to the TBI Model System Index injury, pre-Index injury demographic and behavioral characteristics, Index injury characteristics, post-Index injury behavioral health and global outcome. RESULTS Twenty percent of the cohort experienced TBIs preceding the TBI Model System Index injury-80% of these were mild and 40% occurred before age 16. Pre- and post-Index injury behavioral issues, especially substance abuse, were highly associated with having had a prior TBI. Greater severity of the pre-Index injury as well as occurrence before age 6 often showed stronger associations. Unexpectedly, pre-Index TBI was associated with less severe Index injuries and better functioning on admission and discharge from rehabilitation. CONCLUSIONS Findings suggest that earlier life TBI may have important implications for rehabilitation after subsequent TBI, especially for anticipating behavioral health issues in the chronic stage of recovery. Results provide additional evidence for the potential consequences of early life TBI, even if mild.

Life expectancy following rehabilitation: a NIDRR Traumatic Brain Injury Model Systems study.

Objective:To characterize overall and cause-specific mortality and life expectancy among persons who have completed inpatient traumatic brain injury rehabilitation and to assess risk factors for mortality. Design:Prospective cohort study. Setting:The Traumatic Brain Injury Model Systems. Participants:A total of 8573 individuals injured between 1988 and 2009, with survival status per December 31, 2009, determined. Interventions:Not applicable. Main Outcome Measures:Standardized mortality ratio (SMR), life expectancy, cause of death. Results:SMR was 2.25 overall and was significantly elevated for all age groups, both sexes, all race/ethnic groups (except Native Americans), and all injury severity groups. SMR decreased as survival time increased but remained elevated even after 10 years postinjury. SMR was elevated for all cause-of-death categories but especially so for seizures, aspiration pneumonia, sepsis, accidental poisonings, and falls. Life expectancy was shortened an average of 6.7 years. Multivariate Cox regression showed age at injury, sex, race/ethnic group, marital status and employment status at the time of injury year of injury, preinjury drug use, days unconscious, functional independence and disability on rehabilitation discharge, and comorbid spinal cord injury to be independent risk factors for death. Conclusion:There is an increased risk of death after moderate or severe traumatic brain injury. Risk factors and causes of death have been identified that may be amenable to intervention.

Diagnostic Accuracy of Bedside Swallow Evaluation Versus Videofluoroscopy to Assess Dysphagia in Individuals With Tetraplegia

To assess the accuracy of bedside swallow evaluation (BSE) compared with videofluorosopic swallow study (VFSS) in diagnosing dysphagia in individuals with tetraplegia due to spinal cord injury (SCI).

Impact of late post-traumatic seizures on physical health and functioning for individuals with brain injury within the community.

Primary objective: To better characterize, describe and highlight issues that individuals with TBI and active LPTS may face in their daily lives. Design: Prospective multi-centre mixed method qualitative and quantitative interview. Participants: Twenty-five individuals, 5–13 years post-injury, who had reported having LPTS and TBI. Measures: Disability Rating Scale (DRS); Supervision Rating Scale (SRS); Glasgow Outcome Scale–Extended (GOS-E); Perceived Stress Scale (PSS); Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF) sub-scales: Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration; and Craig Hospital Inventory of Environmental Factors (CHIEF); and qualitative interview questions pertaining to management of the seizure disorder and its effect on the individuals health, function, community integration and participation. Results: Data are presented regarding seizure activity and management; return to driving post-seizure; coping and participation; and standardized outcome measures. Conclusions: Individuals with TBI and LPTS are at a double-barrelled disadvantage regarding ongoing physical, cognitive, psychosocial and reintegration issues following brain injury and epilepsy. Clearer clinical guidelines and treatment strategies need to be developed to help ameliorate these ongoing issues. Additional research is needed to identify what the rehabilitation community can do to continue to facilitate people living safely and independently.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009. DESIGN Secondary data analysis. SETTING Inpatient rehabilitation centers. PARTICIPANTS Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURE Employment. RESULTS Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury. CONCLUSIONS These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.

Dysphagia and respiratory care in individuals with tetraplegia: incidence, associated factors, and preventable complications.

Dysphagia occurs in a significant number of individuals with spinal cord injury (SCI) presenting to acute care and inpatient rehabilitation. This prospective study has found dysphagia in nearly 40% of individuals with tetraplegia. Tracheostomy, mechanical ventilation, nasogastric tube, and age are significant risk factors. The detrimental complications of dysphagia in SCI can cause significant morbidity and delays in rehabilitation. Thus, early and accurate diagnosis of dysphagia is imperative to reduce the risk of developing life-threatening complications. Incidence and risk factors of dysphagia and the use of the bedside swallow evaluation (BSE) and videofluoroscopy swallow study (VFSS) to diagnose dysphagia are presented. The often underappreciated role of respiratory therapists, including assist cough, high tidal volume ventilation, and the use of Passy-Muir valve, in the care of individuals with SCI who have dysphagia is discussed. Improved secretion management and respiratory stabilization enable the individuals with dysphagia to be evaluated sooner and safely by a speech pathologist. Early evaluation and intervention could improve upon morbidity and delayed rehabilitation, thus improving overall clinical outcomes.

The factor structure of the Pittsburgh Sleep Quality Index in persons with traumatic brain injury. A NIDRR TBI model systems module study.

BACKGROUND Sleep disturbances are common following traumatic brain injury (TBI). The Pittsburgh Sleep Quality Index (PSQI) is a widely used measure of sleep quality that has been used in numerous populations. Although this measure has been used in TBI research, there are few studies examining the psychometric properties in this population. OBJECTIVE The current study examined the factor structure of the PSQI in a sample of persons with TBI and tested the one, two, and three factor models derived from previous studies in other populations. METHODS A telephone interview was conducted with 243 individuals who had sustained a TBI. All participants were approximately one year post-injury. Factor analyses were conducted (exploratory and confirmatory) to examine the factor structure of the PSQI. RESULTS Results confirm the fit of models previously tested in the literature but also reveal an alternative conceptualization of sleep containing both qualitative and quantitative factors. CONCLUSIONS While the 3-factor model best fits the data in this TBI sample, the use of a 2-factor model is acceptable and may be more clinically relevant due to the grouping of time-related variables that could provide important information with regard to circadian rhythm disorders.