Faculty Bibliography

BACKGROUND:Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation. OBJECTIVE:This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure. METHODS:Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG). RESULTS:To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea. CONCLUSIONS:Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

Background: Secondary impairments associated with spinal cord injury (SCI) limit one's independent functionality and negatively impact quality of life (QoL). Objective: The purpose of this study was to explore changes in secondary health conditions that may result from using a powered exoskeleton as well as their potential impact on QoL. Methods: Forty-five participants presenting with SCI ranging from T3-L2 were included in this study. Outcome measures included self-reported assessments of pain, spasticity, bladder/bowel function, Satisfaction with Life Scale (SWLS), and Modified Ashworth Scale (MAS). Results: Participants reported significantly less spasticity at the conclusion of the study, 0.9 ± 1.7, compared to baseline, 1.6 ± 0.9 [t (44) = 2.83, p < .001]. MAS testing revealed that 26.7% of participants presented with decreased spasticity at the conclusion of the trial. Participants reported less pain at the end of the trial, 0.9 ± 1.6, compared to the start, 1.1 ± 1.7 [t (44) = 1.42, p > .05]. No negative changes in bowel and bladder were reported; positive changes were reported by 20% and 9% of participants with respect to bowel and bladder management. There was no statistically significant change in SWLS sum score from baseline, 20.4 ± 8.0, to conclusion of the study, 21.3 ± 7.6 [t (44) = -1.1, p > .05]. Conclusion: Findings suggest using a powered exoskeleton may decrease spasticity in people living with SCI. Although improvements in secondary impairments did not result in a significant improvement in QoL, it is believed that using a powered exoskeleton in one's community will lead to increased community integration facilitating an improvement in QoL.

OBJECTIVE:To investigate the contribution of race/ethnicity to retention in traumatic brain injury (TBI) research at 1 to 2 years postinjury. SETTING/METHODS:Community. PARTICIPANTS/METHODS:With dates of injury between October 1, 2002, and March 31, 2013, 5548 whites, 1347 blacks, and 790 Hispanics enrolled in the Traumatic Brain Injury Model Systems National Database. DESIGN/METHODS:Retrospective database analysis. MAIN MEASURE/METHODS:Retention, defined as completion of at least 1 question on the follow-up interview by the person with TBI or a proxy. RESULTS:Retention rates 1 to 2 years post-TBI were significantly lower for Hispanic (85.2%) than for white (91.8%) or black participants (90.5%) and depended significantly on history of problem drug or alcohol use. Other variables associated with low retention included older age, lower education, violent cause of injury, and discharge to an institution versus private residence. CONCLUSIONS:The findings emphasize the importance of investigating retention rates separately for blacks and Hispanics rather than combining them or grouping either with other races or ethnicities. The results also suggest the need for implementing procedures to increase retention of Hispanics in longitudinal TBI research.

OBJECTIVE:To analyze the complex relationship between various social indicators that contribute to socioeconomic status and healthcare barriers. DESIGN/METHODS:Cluster analysis of historical patient data obtained from inpatient visits. SETTING/METHODS:Setting: Inpatient rehabilitation unit in a large, urban university hospital PARTICIPANTS: Adult patients receiving acute inpatient care, predominantly for closed head injury. INTERVENTIONS/METHODS:Not applicable MAIN OUTCOME MEASURES: We examined the membership of TBI patients in various "vulnerable group" (VG) clusters (e.g., homeless, unemployed, racial/ethnic minority) and characterized the rehabilitation outcomes of the patients (e.g., duration of stay, changes in Functional Independence Measure [FIM] scores between admission to inpatient stay and discharge). RESULTS:Analysis revealed four major clusters (i.e., Clusters A-D) separated by VG memberships, with distinct durations of stay and FIM gains during their stay. Cluster B, the largest cluster and also consisting of mostly racial/ethnic minorities, had the shortest duration of hospital stay and one of the lowest FIM improvements among the four clusters despite higher FIM scores at admission. In cluster C, also consisting of mostly ethnic minorities with multiple SES vulnerabilities, patients were characterized by low cognitive FIM scores at admission and the longest duration of stay, and they showed good improvement in FIM scores. CONCLUSIONS:Application of clustering techniques to inpatient data identified distinct clusters of patients who may experience differences in their rehabilitation outcome due to their membership in various "at-risk" groups. Results identified patients (i.e., cluster B, with minority patients and Cluster D, with elderly patients) who attain below-average gains in brain injury rehabilitation. Results also suggested that systemic (e.g., duration of stay) or clinical service improvements (e.g., staff's language skills, ability to offer substance abuse therapy, provide appropriate referrals or liaise with intensive social work services or plan subacute rehabilitation phase) could be beneficial for acute settings. Stronger recruitment, training and retention initiatives for bilingual and multiethnic professionals may also be considered to optimize gains from acute inpatient rehabilitation following traumatic brain injury.

Research Objectives: To investigate and compare the varying impacts non-felony criminal arrests, felony arrest, or both have upon physical, mental, and social functioning longitudinally from onset of TBI to one and two year post-injury follow-up. Design: Data consisted of the Traumatic Brain Injury Model Systems (TBIMS) Form I, Form II, and an expanded incarceration/homelessness questionnaire collected through medical record abstraction and patient self-report at a TBIMS center in New York City. Setting: One urban New York City TBIMS center, including TBI participants from an acute inpatient rehabilitation public and and private hospital. Participants: 239 acute TBI inpatients who received acute care and rehabilitation at a TBIMS center. Participants are predominantly male (79%) and White (36%) or Hispanic (33%). Mean age of 49.0 years (SD= 19.9). Sample includes 45 individuals with a history of incarceration (felony, misdemeanor, overnight stay, arrest). Interventions: Not Applicable. Main Outcome Measures: Data collected through TBIMS Form I & II interviews and an expanded incarceration questionnaire. Results: Chi-squares and t-tests will demonstrate that participants who have reported committing both a criminal arrest (overnight stay, misdemeanors) and a felonious offense experience higher incidences of homelessness, substance use, psychiatric hospitalizations, suicide attempts, less social support, and decreased job stability. Conclusions: Current TBI research has recognized TBI as a chronic disease noting the cognitive and psychological sequela occurring up 10, 20, and even 30 years post-injury. Given the compounding risk with recidivism, coupled with risks of chronic TBI, it is imperative that further research seek to more exhaustively capture all criminal offense class incidences. Furthermore, future research should address the interplay between chronic TBI and incarceration, aiming to resolve the added adverse effects It has upon this vulnerable population

Research Objectives: To investigate and discuss the correlates between TBI and incarceration, as well as the additional difficulties associated with repeat offense as it relates to mental health (i.e., psychiatric hospitalization, suicide attempts) , physical health, and social interaction and functioning (i.e. employment, social support). Design: New York City site of the Traumatic Brain Injury Model Systems (TBIMS) center medical record abstraction and patient self-report data on TBIMS Form I and Form II, and an expanded incarceration/homelessness questionnaire. Setting: One urban New York City TBIMS center, including TBI participants from an acute inpatient rehabilitation public and and private hospital. Participants: 239 acute TBI inpatients who received acute/rehabilitation care at a TBIMS center. Male (79%), White (36%), or Hispanic (33%). Mean age of 49.0 years (SD=19.9). Interventions: Not Applicable. Main Outcome Measures: TBIMS Form I and II interviews and an expanded incarceration questionnaire. Results: Chi-squares and t-tests will demonstrate that offenders (felony and/or non-felony) experience higher incidences of homelessness, substance use, psychiatric hospitalizations, and suicide attempts, which are further exacerbated by repeat offenses. Further, recidivism is also associated with less social support and job stability. Conclusions: Incarceration is a risk-factor for TBI populations and is associated with vulnerable group membership, especially for repeat offenders. Future research should identify subpopulations at higher risk for co-occurrence and design community and correctional interventions to interrupt the cycle of TBI and incarceration

Research Objectives: To primarily investigate the demographics, preinjury characteristics and post-injury outcome correlates between hidden homeless and the traumatic brain injury (TBI) population. To also analyze and broaden the methods of capturing homelessness history and housing instability within the Traumatic Brain Injury Model System (TBIMS). Design: Data consisted of the Traumatic Brain Injury Model Systems (TBIMS) Form I, Form II, and an expanded incarceration/homelessness questionnaire collected through medical record abstraction and patient self-report at a TBIMS center in New York City. Setting: One urban New York City TBIMS center, including TBI participants from an acute inpatient rehabilitation public and private hospital. Participants: 133 acute TBI inpatients who received acute and rehabilitation care at a Traumatic Brain Injury Model Systems (TBIMS) center. Male (85%). Mean age=45.1 years (SD=19.4). Sample includes 42 individuals with a history of housing instability. Interventions: Not applicable. Main Outcome Measures: Data collected through TBIMS Form I & II interviews and an expanded incarceration and homelessness questionnaire. Results: Chi-squares and t-tests will demonstrate that individuals with a history of housing instability are younger, have less social support and job stability, lower education, and are more likely to experience a TBI due to violence. Additionally, they experience higher incidences of substance use and psychiatric hospitalizations pre-injury and more anxiety and depression post-injury. Conclusions: These findings highlight the subsequent adverse social, psychological, and socioeconomic effects having a history of housing instability has upon this already marginalized and underrepresented group. Given this knowledge, efforts should be focused upon broadening current definitions of homelessness, moving towards a more complete and fuller understanding of housing instability