Faculty Bibliography

OBJECTIVE: Posttraumatic seizures (PTS) are well-recognized acute and chronic complications of traumatic brain injury (TBI). Risk factors have been identified, but considerable variability in who develops PTS remains. Existing PTS prognostic models are not widely adopted for clinical use and do not reflect current trends in injury, diagnosis, or care. We aimed to develop and internally validate preliminary prognostic regression models to predict PTS during acute care hospitalization, and at year 1 and year 2 postinjury. METHODS: Prognostic models predicting PTS during acute care hospitalization and year 1 and year 2 post-injury were developed using a recent (2011-2014) cohort from the TBI Model Systems National Database. Potential PTS predictors were selected based on previous literature and biologic plausibility. Bivariable logistic regression identified variables with a p-value < 0.20 that were used to fit initial prognostic models. Multivariable logistic regression modeling with backward-stepwise elimination was used to determine reduced prognostic models and to internally validate using 1,000 bootstrap samples. Fit statistics were calculated, correcting for overfitting (optimism). RESULTS: The prognostic models identified sex, craniotomy, contusion load, and pre-injury limitation in learning/remembering/concentrating as significant PTS predictors during acute hospitalization. Significant predictors of PTS at year 1 were subdural hematoma (SDH), contusion load, craniotomy, craniectomy, seizure during acute hospitalization, duration of posttraumatic amnesia, preinjury mental health treatment/psychiatric hospitalization, and preinjury incarceration. Year 2 significant predictors were similar to those of year 1: SDH, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Corrected concordance (C) statistics were 0.599, 0.747, and 0.716 for acute hospitalization, year 1, and year 2 models, respectively. SIGNIFICANCE: The prognostic model for PTS during acute hospitalization did not discriminate well. Year 1 and year 2 models showed fair to good predictive validity for PTS. Cranial surgery, although medically necessary, requires ongoing research regarding potential benefits of increased monitoring for signs of epileptogenesis, PTS prophylaxis, and/or rehabilitation/social support. Future studies should externally validate models and determine clinical utility.

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.

OBJECTIVE: 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 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 post-injury years 1, 2, 5 and 10 (n=3,618). 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 relationships 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, pre-injury substance misuse, pre-injury vocational status and days of post-traumatic amnesia. Calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all post-employment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years post-injury. CONCLUSIONS: These results confirm that post-injury employment after moderate to severe 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 post-injury suggests that moderate to severe TBI may have unfavorable chronic effects, and/or 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 post-injury is recommended, as are interventions that target influencing factors.

BACKGROUND: If and how much dural penetration influences long-term outcome after traumatic brain injury (TBI) is understudied, especially within the civilian population. OBJECTIVES: Using the large TBI Model Systems cohort, this study assessed and compared penetrating TBI (PTBI) and closed TBI with respect to global outcome and late seizures 2 years after injury. METHODS: After performing unadjusted PTBI versus closed TBI comparisons, multivariate regression models were built and analyzed for both outcomes by including the following additional predictors: length of unconsciousness, posttraumatic amnesia duration, hospital length of stay, age, gender, race, marital status, education level, problem substance abuse, and preinjury employment status. RESULTS: The collapsed Glasgow Outcome Scale model (n = 6111) showed significant secondary effects of PTBI with employment status. When employed before injury, individuals with PTBI were 2.62 times more likely (95% confidence interval, 1.92-3.57) to have a lower Glasgow Outcome Scale category. The final model for late seizures (n = 6737) showed a significant main effect for PTBI. Adjusting for other predictors, individuals with PTBI were 2.78 times more likely (95% confidence interval, 1.93-3.99) than those with closed TBI to be rehospitalized for a seizure. CONCLUSION: This study empirically demonstrates that penetrating injury mechanism has important prognostic implications.

Background: Walking on even surface and stair walking capacity are prerequisites for independence, and these capacities are often referred to as primary goals in rehabilitation after stroke. Purpose: The aim of this study was to establish if differences in walking and stair climbing capacity are present in persons with stroke admitted to specialized rehabilitation in different cultural contexts. Secondary aims were to evaluate if different rehabilitation models influence walking and stair climbing capacity and to find possible explanatory factors. Hypothesis being that there are no differences between capacities at baseline and that the capacity improves independent of rehabilitation models. Methods: The design was a prospective, descriptive study of the specialized rehabilitation of stroke patients in rehabilitation institutions in Norway, PR China, the United States, Russia, Israel, Palestine and Sweden, i.e. in seven different countries, nine clinics in total, Patients with a primary diagnosis of stroke attending an institution for specialized rehabilitation were invited to enroll in the study. The primary outcome measures for the patients were Barthel Index (BI) item 9 and 10 and the Functional Independence Measure (FIM) item 12 and 13. Tests were performed baseline on admission, 18-22 days into rehabilitation, at discharge and 6 months post discharge. Change scores on 18-22 days into rehab were used as indicators for differences between clinics. Results: There were significant differences in walking and stair climbing capacity on admission between the clinics (p < 0.0001) indicating differences in admission criteria. When the differences were controlled for in the further analysis between centers at 18-22 days of rehabilitation, walking capacity and stair climbing were significantly (p < 0.0001) different between centers. These differences may be indicative of differences in time of exercises, d amount of exercise provision, as well as length of stay in the rehabilitation unit. Furthermore in the longitudinal data analysis with repeated measurements from baseline to 6 months a significant difference in both walking ability and stair climbing between the centers maintained indicating the importance of the early rehabilitation for maintenance of capacities. Conclusion(s): This multinational study on transfer, walking and stair climbing in persons with stroke admitted to specialized rehabilitation indicates that the varied content of specialized rehabilitation significantly influences the outcomes of transfer, walking and stair climbing capacity, both within the rehabilitation period and 6 months post discharge. Implications: The study has implications for stroke rehabilitation

OBJECTIVE: To conduct a systematic review of the evidence on interventions for posttraumatic brain injury fatigue (PTBIF). METHODS: Systematic searches of multiple databases for peer-reviewed studies published in English on interventions targeting PTBIF as a primary or secondary outcome through January 22, 2014. Reference sections were also reviewed to identify additional articles. Articles were rated using the 2011 American Academy of Neurology Classification of Evidence Scheme for therapeutic studies. RESULTS: The searches yielded 1526 articles. Nineteen articles met all inclusion criteria: 4 class I, 1 class II/III, 10 class III, and 4 class IV. Only 5 articles examined fatigue as a primary outcome. Interventions were pharmacological and psychological or involved physical activity, bright blue light, electroencephalographic biofeedback, or electrical stimulation. Only 2 interventions (modafinil and cognitive behavioral therapy with fatigue management) were evaluated in more than 1 study. CONCLUSIONS: Despite areas of promise, there is insufficient evidence to recommend or contraindicate any treatments of PTBIF. Modafinil is not likely to be effective for PTBIF. Piracetam may reduce it, as may bright blue light. Cognitive behavioral therapy deserves additional study. High-quality research incorporating appropriate definition and measurement of fatigue is required to explore the potential benefits of promising interventions, evaluate fatigue treatments shown to be effective in other populations, and develop new interventions for PTBIF.