William C. Walker

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.

Characteristics and treatment of headache after traumatic brain injury: a focused review.

Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ, Walker WC: Characteristics and treatment of headache after traumatic brain injury: A focused review. Am J Phys Med Rehabil 2006;85:619–627. Headache is one of the most common complaints in patients with traumatic brain injury. By definition, headache that develops within 1 wk after head trauma (or within 1 wk after regaining consciousness) is referred to as posttraumatic headache (PTH). Although most PTH resolves within 6–12 mos after injury, approximately 18–33% of PTH persists beyond 1 yr. We performed a systematic literature review on this topic and found that many patients with PTH had clinical presentations very similar to tension-type headache (37% of all PTH) and migraine (29% of all PTH). Although there is no universally accepted protocol for treating PTH, many clinicians treat PTH as if they were managing primary headache. As a result of the heterogeneity in the terminology and paucity in prospective, well-controlled studies in this field, there is a definite need for conducting double-blind, placebo-controlled treatment trials in patients with PTH.

Natural History of Headache after Traumatic Brain Injury

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

Motor impairment after severe traumatic brain injury: A longitudinal multicenter study.

Neuromotor impairment is a common sequela of severe traumatic brain injury (TBI) but has been understudied relative to neurocognitive outcomes. This multicenter cohort study describes the longitudinal course of neurological examination-based motor abnormalities after severe TBI. Subjects were enrolled from the four lead Department of Veterans Affairs and Defense and Veterans Brain Injury Center sites. The study cohort consisted of 102 consecutive patients (active duty, veteran, or military dependent) with severe TBI who consented during acute rehabilitation for data collection and completed all follow-up evaluations. Paresis, ataxia, and postural instability measures showed a pattern of improvement over time, with the greatest improvement occurring between the inpatient (baseline) and 6-month follow-up assessments. Involuntary movement disorders were rare at all time points. Two years following acute rehabilitation, more than one-third of subjects continued to display a neuromotor abnormality on basic neurological examination. Persistence of tandem gait abnormality was particularly common.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

Characterization of headache after traumatic brain injury

Background: Headache is a common and persistent symptom following traumatic brain injury (TBI). Headaches following TBI are defined primarily by their temporal association to injury, but have no defining clinical features. To provide a framework for treatment, primary headache symptoms were used to characterize headache. Methods: Three hundred and seventy-eight participants were prospectively enrolled during acute in-patient rehabilitation for TBI. Headaches were classified into migraine/probable migraine, tension-type, or cervicogenic headache at baseline and 3, 6, and 12 months following TBI. Results: Migraine was the most frequent headache type occurring in up to 38% of participants who reported headaches. Probable migraine occurred in up to 25%, tension-type headache in up to 21%, then cervicogenic headache in up to 10%. Females were more likely to have endorsed pre-injury migraine than males, and had migraine or probable migraine at all time points after injury. Those classified with migraine were more likely to have frequent headaches. Conclusions: Our data show that most headache after TBI may be classified using primary headache criteria. Migraine/probable migraine described the majority of headache after TBI across one year post-injury. Using symptom-based criteria for headache following TBI can serve as a framework from which to provide evidence-based treatment for these frequent, severe, and persistent headaches.

Systematic Review of Interventions for Post-traumatic Headache

Headache is one of the most common physical symptoms after traumatic brain injury (TBI). The specific goals of this review include (1) determination of effective interventions for post‐traumatic headache (PTHA), (2) development of treatment recommendations, (3) identification of gaps in the current medical literature regarding PTHA treatment, and (4) suggestions for future directions in research to improve outcome for persons with PTHA.

A multicentre study on the clinical utility of post-traumatic amnesia duration in predicting global outcome after moderate-severe traumatic brain injury

Background: Past research shows that post-traumatic amnesia (PTA) duration is a particularly robust traumatic brain injury (TBI) outcome predictor, but low specificity limits its clinical utility. Objectives: The current study assessed the relationship between PTA duration and probability thresholds for Glasgow Outcome Scale (GOS) levels. Methods: Data were prospectively collected in this multicentre observational study. The cohort was a consecutive sample of rehabilitation patients enrolled in the National Institute on Disability and Rehabilitation Research funded TBI Model Systems (n = 1332) that had documented finite PTA duration greater than 24 h, and 1-year and 2-year GOS. Results: The cohort had proportionally more Good Recovery (44% vs 39%) and less Severe Disability (19% vs 23%) at year 2 than at year 1. Longer PTA resulted in an incremental decline in probability of Good Recovery and a corresponding increase in probability of Severe Disability. When PTA ended within 4 weeks, Severe Disability was unlikely (<15% chance) at year 1, and Good Recovery was the most likely GOS at year 2. When PTA lasted beyond 8 weeks, Good Recovery was highly unlikely (<10% chance) at year 1, and Severe Disability was equal to or more likely than Moderate Disability at year 2. Conclusions: Two PTA durations, 4 weeks and 8 weeks, emerged as particularly salient GOS probability thresholds that may aid prognostication after TBI.

Gender differences in executive functions following traumatic brain injury

The present study used the National Institute on Disability Rehabilitation and Research (NIDRR) funded Traumatic Brain Injury Model Systems (TBIMS) database to examine the effect of gender on presentation of executive dysfunction following traumatic brain injury (TBI) and variables that might impact the course and degree of recovery. The Wisconsin Card Sort Test (WCST) was chosen as a measure of executive function which has good credentials without reports of gender effects. Female subjects performed significantly better on the WCST than male subjects as shown by analyses of variance on scores of 1,331 patients for Categories Achieved (means for females = 4.09, males = 3.67, p = .003) and Perseverative Responses (means for females = 32.17, males = 36.42, p = .003). Outperformance by females was also noted in additional ANOVAs examining the interaction of education and gender, and ethnicity and gender in relation to Categories Achieved (p < .01), and for ethnicity and gender in relation to Perseverative Responses (p < .01). A multiple logistic regression revealed that gender, minority status, education level, history of illicit drug use, cause of injury, and length of coma each contributed uniquely to predicting Categories Achieved on the WCST. Simple logistic regression analyses showed that, of these variables, gender and cause of injury (violent vs. non-violent) were the strongest predictors. In contrast, when examining Perseverative Responses, regression analyses found gender, minority status and length of coma predicted impairment. Simple logistic regression analyses showed that, of these three variables, gender and minority status were most robust in predicting impaired Perseverative Responses scores. Implications of these findings are discussed and recommendations for further research are offered.