Traumatic Brain Injury Patient-Reported Outcome Measure: Identification of Health-Related Quality-of-Life Issues Relevant to Individuals With Traumatic Brain Injury

IPV survivors' and service providers' perspectives on brain injury screening/evaluation process and impact

This study explores the perspectives of intimate partner violence (IPV) survivors and staff of brain injury (BI) screening, and the neuropsychological evaluation (NPE) process. We gathered qualitative data from 17 participants - 10 IPV survivors, at risk for a BI, who had received BI screening and a NPE and a total of 7 staff in IPV-serving organizations. Interviews were recorded, transcribed verbatim and analysed for key themes using thematic analysis. Survivors were over 18 years of age; the majority were between 19 and 45 years old, unemployed, unmarried, and had children. Survivors were angry, scared, and embarrassed to learn that they might have an IPV-related BI. They were thankful to have an explanation for some of their cognitive symptoms, which disrupted their daily activities, social relationships, and overall quality of life. Staff were pleased to be able to provide valuable information to their clients that could have a positive impact on their wellbeing. Overall, screening for a BI and participation in the NPE were well tolerated by IPV survivors with a possible BI. Inclusion of the perspectives of IPV survivors and support staff is an essential first step to better understanding their needs so interventions can be developed to aid their recovery.

Research considerations for prospective studies of patients with coma and disorders of consciousness

Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.

The feasibility, acceptability, and effectiveness of the multimodal, community-based LoveYourBrain Retreat program for people with traumatic brain injury and caregivers

PURPOSE

To evaluate the feasibility, acceptability, and effectiveness of the LoveYourBrain Retreat program using a pre-post, retrospective, concurrent triangulation mixed methods study.

MATERIALS AND METHODS

A 5-day, multimodal, residential Retreat intervention was designed to improve quality of life among traumatic brain injury (TBI) survivors and caregivers through mindfulness, movement, nutrition, art, and community-building. Eligibility included being a TBI survivor (>2 years post-injury) or caregiver, 18+ years old, independently mobile, able to communicate verbally, and a first-time participant. Self-reported quantitative and qualitative data were collected via electronic surveys pre- and post-retreat, analyzed separately, then combined. Paired t-tests assessed mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and NIH TBI/Neuro-QOL Resilience, Cognition, Positive Affect/Wellbeing, and Emotional/Behavioral Dysregulation scales. We assessed feasibility using sample characteristics and program frequency and retention, and acceptability using quality ratings. Content analysis explored perceived benefits and improvements.

RESULTS

68 People-53 with TBI and 15 caregivers-participated in one of three LoveYourBrain Retreats. Significant improvements were found in QOLIBRI-OS (6.91, 95%CI 1.88-11.94), Resilience (2.14, 95%CI 0.50-3.78), Cognition (2.81, 95%CI 0.79-4.83), and Emotional/Behavioral Dysregulation (2.84, 95%CI 0.14-5.54) among TBI survivors (n = 41). Mean satisfaction was 9.6/10 (SD = 0.64). Content analysis revealed community connection, reframing TBI experience, self-regulation, and self-care themes.

CONCLUSIONS

The LoveYourBrain Retreat is feasible, acceptable, and may be effective complementary rehabilitation to improve QOL among TBI survivors.

Deployment-related concussion and long-term health-related quality of life among US military personnel

PURPOSE

To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel.

METHODS

The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates.

RESULTS

A lower PCS score was observed in participants with concussion with LOC (B =  - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B =  - 4.84, p < 0.001; MCS: B =  - 10.53, p < 0.001) and depression (PCS: B =  - 2.85, p < 0.001; MCS: B =  - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL.

CONCLUSION

Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.

Neurological Health: Not Merely the Absence of Disease: Current Wellbeing Instruments Across the Spectrum of Neurology

OBJECTIVE

Well-being and quality of life can vary independently of disease. Instruments measuring well-being and quality of life are commonly used in neurology, but there has been little investigation into the extent in which they accurately measure wellbeing/quality of life or if they merely reflect a diseased state of an individual.

DESIGN

Systematic searches, thematic analysis and narrative synthesis were undertaken. Individual items from instruments represented in ≥ 5 publications were categorised independently, without prior training, by five neurologists and one well-being researcher, as relating to 'disease-effect' or 'Well-being' with a study-created instrument. Items were additionally categorised into well-being domains.

DATA SOURCES

MEDLINE, EMBASE, EMCARE and PsycINFO from 1990 to 2020 were performed, across the 13 most prevalent neurological diseases.

RESULTS

301 unique instruments were identified. Multiple sclerosis had most unique instruments at 92. SF-36 was used most, in 66 studies. 22 instruments appeared in ≥ 5 publications: 19/22 'well-being' outcome instruments predominantly measured disease effect (Fleiss kappa = .60). Only 1/22 instruments was categorised unanimously as relating to well-being. Instruments predominantly measured mental, physical and activity domains, over social or spiritual.

CONCLUSIONS

Most neurological well-being or quality-of-life instruments predominantly measure disease effect, rather than disease-independent well-being. Instruments differed widely in well-being domains examined.

Assessment of quality of life after upper extremity transplantation: Framework for patient-reported outcome scale domains

Upper extremity transplantation offers the promise of restored function and regained quality of life (QOL) for individuals who have sustained hand or arm amputation. However, a major challenge for this procedure becoming an accessible treatment option for patients is the lack of standard measures to document benefits to QOL. Patient-reported outcomes (PRO) measures are well-suited for this kind of intervention, where the perspective of the patient is central to defining treatment success. To date, qualitative work with experts, clinicians, and patients has been used to identify the most important domains of QOL for PRO item development. Specifically, our group's qualitative work has identified several domains of QOL that are unique to individuals who have received upper extremity transplants, which are distinct from topics covered by existing PRO measures. These include emotional and social aspects of upper extremity transplant, such as Expectations and Perceived Outcomes, Integration and Assimilation of Transplant, Fitting in, and Post-Surgical Challenges and Complications. The broad topic of Satisfaction with Transplant was subdivided into three subtopics: Function, Sensation, and Aesthetics. Satisfaction with Sensation was also identified as a unique domain not evaluated by existing PRO measures. This report operationalizes these eight QOL domains by presenting scoping definitions. This manuscript describes the work that has been completed for domain characterization as an early step toward developing standardized PRO measures to evaluate these important outcomes specific to upper extremity transplantation.

Indicators of life success from the perspective of individuals with traumatic brain injury: a scoping review

PURPOSE

The purpose was to synthesize qualitative literature and identify indicators of life success (positive life outcomes and experiences) that can help in understanding resiliency in the context of traumatic brain injury (TBI).

METHODS

This scoping review involved searching nine online databases for population (TBI) and context (qualitative literature). Searches retrieved 42 852 articles and, after two-stage screening, 76 articles met the inclusion criteria of reporting indicators of life success from the perspective of individuals with TBI.

RESULTS

Most studies were conducted in North America, Australia, or Europe. Participants were people living with TBI (mild to severe), of all age ranges. Positive life experiences were organized within four domains: understanding of oneself and one's life, social relationships and interaction, doing (engagement in activities, sense of control and accomplishment), and hope for the future.

CONCLUSIONS

The positive life experiences reflect both processes and outcomes (indicators of success) and highlight the need for a multidimensional approach when seeking to understand resiliency following TBI. The transactional framework of life experiences can be applied in future TBI resiliency research to understand how individuals negotiate adversity through experiences promoting understanding of oneself and the world, social relationships, engagement in activity and hope. Implications for rehabilitationRehabilitation services should consider how to afford opportunities for engagement in activity, social interaction, meaning making (i.e., coming to new understandings), and hope.With respect to engaging in activity and social relationships, having social interaction, being understood, being active and productive, having autonomy, and having accomplishments, reflect important experiences to enable within rehabilitation services.Rehabilitation professionals should consider how providing opportunities for their clients to have positive life experiences may contribute toward an adaptive and empowered mindset.

Comparison of health-related quality of life in patients with traumatic brain injury, subarachnoid haemorrhage and cervical spine disease

PURPOSE

The degree of disability that is acceptable to patients following traumatic brain injury (TBI) continues to be debated. While the dichotomization of outcome on the Glasgow Outcome Score (GOSE) into 'favourable' and 'unfavourable' continues to guide clinical decisions, this may not reflect an individual's subjective experience. The aim of this study is to assess how patients' self-reported quality of life (QoL) relates to objective outcome assessments and how it compares to other debilitating neurosurgical pathologies, including subarachnoid haemorrhage (SAH) and cervical myelopathy.

METHOD

A retrospective analysis of over 1300 patients seen in Addenbrooke's Hospital, Cambridge, UK with TBI, SAH and patients pre- and post- cervical surgery was performed. QoL was assessed using the SF-36 questionnaire. Kruskal-Wallis test was used to analyse the difference in SF-36 domain scores between the four unpaired patient groups. To determine how the point of dichotomization of GOSE into 'favourable' and 'unfavourable' outcome affected QOL, SF-36 scores were compared between GOSE and mRS.

RESULTS

There was a statistically significant difference in the median Physical Component Score (PCS) and Mental Component Score (MCS) of SF-36 between the three neurosurgical pathologies. Patients with TBI and SAH scored higher on most SF-36 domains when compared with cervical myelopathy patients in the severe category. While patients with Upper Severe Disability on GOSE showed significantly higher PC and MC scores compared to GOSE 3, there was a significant degree of variability in individual responses across the groups.

CONCLUSION

A significant number of patients following TBI and SAH have better self-reported QOL than cervical spine patients and patients' subjective perception and expectations following injury do not always correspond to objective disability. These results can guide discussion of treatment and outcomes with patients and families.

Domains and measures of social cognition in acquired brain injury: A scoping review

In acquired brain injury (ABI), social cognition is a contributing factor to the changes observed in functional outcomes. However, progress in assessing and understanding social cognitive impairments is limited by a lack of consistency in terminology and the proliferation in assessment tools, leading to a lack of consensus on what should be assessed and how. This review aims to examine the domains of social cognition commonly assessed in ABI, the assessment tools used, and the appropriateness of these tools for researchers and clinicians. Using the Arksey and O'Malley scoping review methodology, 367 articles reporting results from 10,930 people with an ABI met our inclusion criteria. The five most commonly assessed domains of social cognition were emotion perception, theory of mind, social communication, identity recognition and empathy. The most commonly used measure of these domains included: the Ekman and Friesen photo series, Faux Pas Recognition Test, La Trobe Communication Questionnaire, Benton Facial Recognition Test and the Interpersonal Reactivity Index. There are well-validated measures readily available that are underused in favour of non-standardized measures clinically or the development of one's own measure in research. The appropriateness of the identified measure for research and clinical use was discussed, including suggestions for future research.

Social problem solving and trait socioemotional abilities in ambulatory stroke patients

INTRODUCTION

Stroke has been associated with sociocognitive impairment, so far well documented for emotion recognition and Theory of Mind. However, more complex abilities, such as social problem solving, which directly facilitate appropriate behavior in social situations have been neglected in previous research.

METHOD

The present study aimed to address this gap by focusing on performance-based social problem solving abilities and self-reported socioemotional abilities (i.e., empathy and alexithymia) in outpatient stroke patients (n = 36) compared to a group of healthy controls (n = 36) equivalent on age, gender, and education. In further analyses, potential lateralization effects and correlations between social problem solving/socioemotional functioning and demographic and clinical data were investigated.

RESULTS

In the main analyses, patients were impaired in their ability to freely generate appropriate solutions for challenging interpersonal situations depicted in written scenarios but performed on a comparable level as healthy controls when they had to choose the optimal solution presented amidst a range of less optimal options. While showing difficulty in identifying the awkward elements in the scenarios, the patient group nevertheless rated the degree of discomfort attributed to these elements on a level comparable to the control group. On the self-report measures, stroke patients reported overall higher degrees of alexithymia (i.e., an inability to describe and identify one's own and other persons´ emotions) and more personal distress in response to other individuals´ emotional suffering as assessed by self-report.

CONCLUSIONS

The present results suggest that stroke is associated with a broad impact on socioemotional and social problem solving abilities. As difficulties in social problem solving might be associated with increased psychosocial burden they ought to be addressed in stroke rehabilitation.

Survey Results of Speech-Language Pathologists Working With Cognitive-Communication Disorders: Improving Practices for Mild Cognitive Impairment and Early-Stage Dementia From Alzheimer's Disease

PURPOSE

As the incidence of Alzheimer's disease (AD) continues to rise, there is a need for interventions that focus on risk reduction and early disease management. Speech-language pathologists (SLPs) can contribute to risk reduction efforts and deliver cognitive interventions; however, the nature and frequency of current clinical practice in those areas is unclear. Therefore, the purpose of this study was to conduct an exploratory survey of the cognitive-communication practices and needs of SLPs for adults with mild cognitive impairment (MCI) and early-stage dementia from AD, to inform future research and clinical training efforts.

METHOD

SLPs completed an online survey that assessed five areas of practice specific to cognitive-communication and MCI and early-stage dementia: (a) education and training, (b) MCI subtype knowledge and consideration, (c) goals and treatment practices, (d) assessment of everyday living skills, and (e) general clinical practices and needs.

RESULTS

One hundred fifty-seven SLPs completed the survey and represented a range of practice experience. Results revealed a discrepancy between the number of SLPs who provide services to adults with MCI or early-stage dementia and those who have received formal training to do so, suggesting a reliance on clinical practice experience. Participants primarily reported using interview and informal methods to assess daily activities and often described using compensatory-based treatments.

CONCLUSIONS

These findings contribute to the limited knowledge about SLPs' cognitive-communication practices to help improve early-disease management for AD, a rapidly growing population in need of SLPs' services. More research is needed to support SLPs in being maximally effective when working with clients early in the AD continuum.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19787728.

The emotional burden of caregiving for patients with cirrhosis

Caregivers for patients with cirrhosis face immense physical and psychological strain that negatively impact quality of life and ability to care for oneself. The aim is to explore the caregiver experience for patients with cirrhosis, identify prominent stressors, and understand the multidimensional contributors to caregiver burden, to help tailor effective interventions. The caregivers of 25 patients with decompensated cirrhosis underwent semistructured in‐person interviews and completed written exercises targeting emotional disclosure or resilience training that were analyzed for dominant emotions and themes. Burden was quantified using the Zarit Burden Interview‐12 (ZBI, range 0–48), Distress Thermometer (0–10), and Caregiver Captivity Index (0–4). Quality of life was assessed with a visual analog scale (0–100). Median ZBI was moderate (14 [10–19]), as was distress (5 [2–7]), and captivity (2 [1–4]). Quality of life was fair (80 [70–85]). Dominant emotions included anxiety, guilt, fear, frustration, captivity, and resentment. Prominent themes included lack of time for self‐care, hierarchy of caregiver role, support from versus frustration with medical professionals, social support, spirituality and religion, and disease‐related restrictions. Hepatic encephalopathy, and need to follow strict nutrition and diet recommendations, are frequent sources of disease‐related caregiver burden. The health care system confers some degree of burden, especially when doubts arise regarding physician competence. Conclusion: Caregiver burden is significant. The impact of interventions to alleviate caregiver burden should be explored, so that their appreciated efforts do not have such detrimental effects on their quality of life.

Relationships of self-awareness and facial affect recognition to social communication ability in persons with traumatic brain injury

Traumatic brain injury (TBI) can cause changes to the injured person's physical ability, cognitive functioning, and social interactions. Since these attributes largely determine a person's concept of who they are, TBI poses a threat to sense of self. Due to the importance of social communication skills for community integration, impairment of these skills is a particular threat to sense of self. The present investigation sought to explore characteristics that influence social communication abilities. We hypothesized that both ability to interpret facial affect and self-awareness would be associated with communication ability. We also expected that facial affect recognition would influence self-awareness and that the effect of facial affect recognition on social communication would be partially mediated by self-awareness. For this prospective cohort study, participants were 77 individuals with documented TBI. Of these, 65% were male and 83% sustained severe injuries. The hypothesized association of facial affect recognition with social communication was demonstrated with path analysis as was the effect of facial affect recognition on self-awareness. However, the effect of facial affect recognition on social communication was not mediated by self-awareness. In addition, social communication was associated with employment, social integration, and loneliness. Findings highlighted the importance of social communication after TBI.

Machine Learning for Predicting Discharge Disposition After Traumatic Brain Injury

BACKGROUND

Current traumatic brain injury (TBI) prognostic calculators are commonly used to predict the mortality and Glasgow Outcome Scale, but these outcomes are most relevant for severe TBI. Because mild and moderate TBI rarely reaches severe outcomes, there is a need for novel prognostic endpoints.

OBJECTIVE

To generate machine learning (ML) models with a strong predictive capacity for trichotomized discharge disposition, an outcome not previously used in TBI prognostic models. The outcome can serve as a proxy for patients' functional status, even in mild and moderate patients with TBI.

METHODS

Using a large data set (n = 5292) of patients with TBI from a quaternary care center and 84 predictors, including vitals, demographics, mechanism of injury, initial Glasgow Coma Scale, and comorbidities, we trained 6 different ML algorithms using a nested-stratified-cross-validation protocol. After optimizing hyperparameters and performing model selection, isotonic regression was applied to calibrate models.

RESULTS

When maximizing the microaveraged area under the receiver operating characteristic curve during hyperparameter optimization, a random forest model exhibited top performance. A random forest model was also selected when maximizing the microaveraged area under the precision-recall curve. For both models, the weighted average area under the receiver operating characteristic curves was 0.84 (95% CI 0.81-0.87) and the weighted average area under the precision-recall curves was 0.85 (95% CI 0.82-0.88).

CONCLUSION

Our group presents high-performing ML models to predict trichotomized discharge disposition. These models can assist in optimization of patient triage and treatment, especially in cases of mild and moderate TBI.

Critical and Creative Thinking and Photovoice: Strategies for Strengthening Participation and Inclusion

Researchers, nonprofit organizations, and others have long used photovoice as a participatory action research method with vulnerable groups to depict, reflect on, and describe their realities, and advocate for change. Paulo Freire, whose scholarship is a foundation of photovoice, encouraged critical thinking in a popular education process to understand "the 'why' of things and facts." Creative thinking, a complementary concept that emerged in the field of education in the 1990s, involves, at its core, development, implementation, and communication of multiple original ideas. We provide a model of critical and creative thinking as an integrated process that generates knowledge as participants complete four key photovoice steps: (1) answer questions with a camera, (2) communicate in the group, (3) observe commonalities, and (4) communicate to power. We argue that each step involves teachable skills and provide practical, low-tech strategies that photovoice facilitators can use to enhance critical and creative thinking by any participant who finds it challenging to complete the four steps. Bringing a critical and creative thinking process to photovoice facilitation grounds the method in its education roots. It can enhance participation and inclusion of any vulnerable group, including people with cognitive and communication disorders due to acquired brain injury, mental illness, or substance use disorder for example. We suggest that use of the suggested strategies will result in an authentic, meaningful process that helps equalize power relationships, respects individuals as experts on their own lives, and increases the potential for data that prompt action.

Responsiveness of the Traumatic Brain Injury Quality of Life Cognition Banks in Recent Brain Injury

Patient report of functioning is one component of the neurocognitive exam following traumatic brain injury, and standardized patient-reported outcomes measures are useful to track outcomes during rehabilitation. The Traumatic Brain Injury Quality of Life measurement system (TBI-QOL) is a TBI-specific extension of the PROMIS and Neuro-QoL measurement systems that includes 20 item banks across physical, emotional, social, and cognitive domains. Previous research has evaluated the responsiveness of the TBI-QOL measures in community-dwelling individuals and found clinically important change over a 6-month assessment interval in a sample of individuals who were on average 5 years post-injury. In the present study, we report on the responsiveness of the TBI-QOL Cognition–General Concerns and Executive Function item bank scores and the Cognitive Health Composite scores in a recently injured sample over a 1-year study period. Data from 128 participants with complicated mild, moderate, or severe TBI within the previous 6 months were evaluated. The majority of the sample was male, white, and non-Hispanic. The participants were 18–92 years of age and were first evaluated from 0 to 5 months post-injury. Eighty participants completed the 1-year follow-up assessment. Results show acceptable standard response mean values (0.47–0.51) for all measures and minimal detectable change values ranging from 8.2 to 8.8 T-score points for Cognition–General Concerns and Executive Functioning measures. Anchor rating analysis revealed that changes in scores on the Executive Function item bank and the Cognitive Health Composite were meaningfully associated with participant-reported changes in the areas of attention, multitasking, and memory. Evaluation of change score differences by a variety of clinical indicators demonstrated a small but significant difference in the three TBI-QOL change scores by TBI injury severity grouping. These results support the responsiveness of the TBI-QOL cognition measures in newly injured individuals and provides information on the minimal important differences for the TBI-QOL cognition measures, which can be used for score interpretation by clinicians and researchers seeking patient-reported outcome measures of self-reported cognitive QOL after TBI.

CONNECT: A pragmatic clinical trial testing a remotely provided linkage to service coordination after hospitalization for TBI

OBJECTIVE

To test whether a complex behavioral intervention delivered remotely to connect individuals to clinical resources after hospitalization for TBI improved their quality of life.

DESIGN/METHODS

Community-based randomized pragmatic clinical trial. Main measures TBI-QOL, Activity Measure for Post-Acute Care (AM-PAC), Clinical Satisfaction and Competency Rating Scale.

RESULTS

332 individuals ≥18 years-old hospitalized for TBI in four upper Midwest states were randomized to Remote (n = 166) and Usual Care (n = 166) groups. The groups were equivalent and representative of their state population's racial and ethnic composition, age, and proportion living in rural communities. There were no significant differences within or between experimental groups over the study period in TBI-QOL t-scores. There was a significant improvement in AM-PAC Daily Activities within the Remote group and a significant between-group improvement in clinical satisfaction for the Remote group.

CONCLUSION

Enrolling a representative, regional community-based sample of individuals with TBI can be successful, and delivering a customized complex behavioral intervention remotely is feasible. The overall lack of intervention effectiveness was likely due to enrolling individuals without pre-identified clinical needs, initiating intervention after the immediate post-acute phase when needs are often highest, inability to provide direct clinical care remotely, and potential lack of outcome measure responsiveness in our sample.

Low resilience following traumatic brain injury is strongly associated with poor neurobehavioral functioning in U.S. military service members and veterans

OBJECTIVE

The purpose of this study was to examine the relationship between resilience and self-reported neurobehavioral functioning following traumatic brain injury (TBI) in U.S. military service members and veterans (SMVs). A secondary objective was to examine the interaction between resilience and posttraumatic stress disorder (PTSD) on neurobehavioral functioning.

METHOD

Participants included 795 SMVs classified into four groups: Uncomplicated Mild TBI (MTBI; n=300); Complicated Mild, Moderate, Severe, or Penetrating TBI (STBI, n 162); Injured Controls (IC, n=185); and Non-injured Controls (NIC, n=148). Two independent cohorts were evaluated - those assessed within 1-year of injury and those assessed 10-years post-injury. SMVs completed self-report measures including the PTSD Checklist-Civilian version, Neurobehavioral Symptom Inventory, and TBI-Quality of Life.

RESULTS

Results showed that (1) lower resilience was strongly associated with poorer neurobehavioral functioning across all groups at 1-year and 10-years post-injury, and (2) PTSD and resilience had a robust influence on neurobehavioral functioning at both time periods post-injury, such that SMVs with PTSD and low resilience displayed the poorest neurobehavioral functioning.

CONCLUSION

Results suggest that regardless of injury group and time since injury, resilience and PTSD strongly influence neurobehavioral functioning following TBI among SMVs. Future research evaluating interventions designed to enhance resilience in this population is indicated.

Improvement in postural alignment is associated with recovery of mobility after complex acquired brain injury: An observational study

PURPOSE

Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time.

METHODS

Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models.

RESULTS

Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking.

CONCLUSION

Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.

Should I Stay or Should I Go? Identifying Intrinsic and Extrinsic Factors in the Decision to Return to Duty Following Lower Extremity Injury

INTRODUCTION

Rehabilitation research of wounded service members (SMs) commonly focuses on physical ability to return to duty (RTD) as a measure of successful recovery. However, numerous factors or barriers may influence a SM's ability and/or desire to RTD after lower extremity musculoskeletal trauma. SMs themselves as well as the clinical care team that works with them daily, often for years at a time, both offer unique perspectives on the influential factors that weigh into decisions to RTD. The purpose of this study was to identify the intrinsic and extrinsic factors patients and clinicians recognized as influencing the decision to RTD after severe lower extremity trauma.

MATERIALS AND METHODS

Thirty-two SMs with severe lower extremity trauma (amputation and lower limb salvage) and 30 providers with at least 2 years' experience caring for SMs with similar injuries participated separately in either a SM or provider/clinician focus group. Open-ended questions on factors influencing RTD and other rehabilitation success were discussed. Data analysis consisted of qualitative transcription and participatory active sorting, followed by thematic coding and grouping of qualitative data.

RESULTS

Individual (health condition, personal traits, and career consideration), interpersonal (clinician's impact, family influence, and peer influence), health care system (systems of care, transdisciplinary rehabilitation, and innovation availability), and institutional (policy, benefits, and unit/commander) themes emerged amongst SM patients and clinicians. Expected frequently occurring themes common to both groups were the influence of the team and family unit, as well as career trajectory options after a severe injury. An unexpected theme was acknowledgment of and dissatisfaction with the recent dismantling of institutional systems that support wounded SMs. Patients placed less emphasis on severity of injury and greater emphasis on system and policy barriers than did clinicians.

CONCLUSIONS

Characterization and classification of these clinician and SM-identified factors that influence the decision to RTD after severe lower extremity trauma is expected to improve the efficacy of future rehabilitation efforts and clinical practice guidelines by providing the clinical team the knowledge necessary to recognize modifiable barriers to patient success. A better understanding of factors influencing RTD decision-making may support policies for mitigating RTD barriers, better monitoring of the changing landscape of RTD after lower extremity trauma, improving systems of health care, and/or reducing turnover and facilitating force readiness.

Integrated neuropsychological and cognitive behavioural therapy after acquired brain injury: A pragmatic randomized clinical trial

After acquired brain injury (ABI) many patients suffer from persistent cognitive and emotional disturbances. The aim of this study was to investigate the treatment outcome of an integrated intervention, combining neuropsychological and cognitive behavioural therapy (nCBT), against waitlist (WL) in outpatients with ABI. Individuals seeking outpatient treatment for cognitive and emotional problems after ABI were randomly allocated to nCBT (n = 27) or WL (n = 29) and completed assessments at baseline, post-treatment/WL and at six-month follow-up. The primary outcome measures were general psychopathology and functional activity in daily life. The nCBT group showed significant improvement for general psychopathology post-treatment when compared to WL. nCBT was also superior to WL regarding the secondary outcomes, i.e., the reduction of negative affect and the improvement of quality of life. No significant differences for functional activity and community integration were observed. Significant pre-post effect sizes ranged between small for functional activity and medium for quality of life. The positive effects were maintained at follow-up. The majority of patients with cognitive and emotional problems after ABI benefit from an integrated approach that offers cognitive remediation and psychotherapy. However, the heterogeneous sequelae of ABI and the moderate sample sizes in clinical trials present a methodological challenge to ABI research.

Deprescribing medications that may increase the risk of hepatic encephalopathy: A qualitative study of patients with cirrhosis and their doctors

Background and Aims

Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis.

Methods

We conducted, transcribed, and analyzed semi‐structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing.

Results

Major provider‐specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient‐specific barriers included knowledge gaps regarding the cirrhosis‐specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach.

Conclusion

Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy‐based deprescribing outreach and patient‐facing education on risks are warranted.

Summarize the established knowledge on this subject

Hepatic encephalopathy (HE) is a morbid complication of cirrhosis.

The risk of HE may be increased by psychoactive medications and proton pump inhibitors.

Deprescribing is felt to be a promising approach to HE prevention.

What are the significant and/or new findings of this study?

Patients are unaware of how their medications influence the risk of HE.

Patients are willing to follow physician recommendations regarding deprescribing but are afraid of worsening symptoms.

Physicians do not feel comfortable deprescribing opioids or benzodiazepines.

Physicians do not feel responsible or equipped with the resources for deprescribing.

Effect of age at time of injury on long-term changes in intrinsic functional connectivity in traumatic brain injury

BACKGROUND

Alterations in resting-state functional connectivity (rsFC) occur in the acute and chronic phases following traumatic brain injury (TBI); however, few studies have assessed long-term (>1 year) changes in rsFC.

METHODS

Resting-state functional magnetic resonance imaging (rsfMRI) scans were obtained from the Federal Interagency Traumatic Brain Injury Research Informatics Systems. Patients with primarily mild TBI (n = 39) completed rsfMRI scans at the sub-acute (~10 days) and long-term (~18 months) phases. We examined changes in voxel-based rsFC from anterior medial prefrontal cortex (aMPFC) and posterior cingulate cortex (PCC) seeds in the default mode network (DMN) between both phases. The effect of age at the time of injury on long-term rsFC was also examined.

RESULTS

Increased rsFC from the aMPFC and the PCC to frontal and temporal regions was shown at ~18-months post-injury. Widespread increases in rsFC from the aMPFC and between the PCC and frontal regions were shown for younger patients at time of injury, but limited increases of rsFC were noted at ~18 months in older patients.

CONCLUSION

Long-term increases in rsFC were found following TBI, but age at the time of injury was associated with distinct rsFC profiles suggesting that younger patients show greater increases in rsFC over time.

Development of the TBI-QOL Headache Pain Item Bank and Short Form

OBJECTIVE

To develop, calibrate, and evaluate the test-retest reliability of a new patient-reported outcome measure of headache pain relevant for individuals with traumatic brain injury (TBI).

SETTING

Six TBI Model Systems rehabilitation centers in the United States.

PARTICIPANTS

Adults with medically confirmed documentation of TBI.

DESIGN

Cross-sectional calibration field testing and test-retest reliability analyses.

MAIN MEASURES

Traumatic Brain Injury-Quality of Life Headache Pain item bank.

RESULTS

Thirteen headache pain items were calibrated as a unidimensional measure using data from 590 participants. The new measure was reliable (α = .98; item-total correlation range: 0.71-0.91). Item parameter estimates were estimated using Samejima's Graded Response Model and a 10-item calibrated short form was created. Simulation testing confirmed that both the computer-adaptive test and the short-form administrations were equivalent to the full item bank. One- to-2-week test-retest reliability of the computer-adaptive test was high (Pearson r and intraclass correlation coefficients = 0.81). Approximately two-thirds of the sample reported at least 1 headache symptom.

CONCLUSION

The Traumatic Brain Injury-Quality of Life Headache Pain item bank and short form provide researchers and clinicians with reliable measures of the subjective experience of headache symptoms for individuals with a history of TBI.

Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.

METHODS

A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.

RESULTS

A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128-0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53-0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05-16.7) and older age (continuous HR 1.03, 95% CI 1.009-1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.

CONCLUSIONS

Inpatient and postdischarge mortality remain high following admission to Uganda's main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Establishing the Factor Structure of a Health-Related Quality of Life Measurement System for Caregivers of Persons Living With Traumatic Brain Injury

OBJECTIVES

To understand the factor structure of health-related quality of life specific to caregivers of people living with traumatic brain injury (TBI).

DESIGN

Prospective, cross-sectional data collection.

SETTING

Three TBI Model Systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=558) of people who have sustained a TBI (344 caregivers of civilians and 214 caregivers of service members or veterans; 85% women; 58% spouses; mean age, 46.12±14.07y) who have provided care for an average of 5.82±5.40 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

The Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) measurement system including 10 Patient-Reported Outcomes Measurement Information System item banks (anger, anxiety, depression, social isolation, sleep disturbance, fatigue, ability to participate in social roles and activities, satisfaction with social roles and activities, emotional support, informational support) and 5 TBI-CareQOL banks (feelings of loss-self, feelings of loss-person with TBI, feeling trapped, caregiver-specific anxiety, caregiver strain).

RESULTS

Confirmatory factor analysis model fit indices were compared for 14 empirically derived and 5 theoretically derived models. Confirmatory factor analysis results indicated that the best model fit was for a 6-factor model with dimensions that included mental health, social support, social participation, social isolation, physical health, and caregiver emotion.

CONCLUSIONS

Results indicated that a 6-factor model provided the best model fit for health-related quality of life in caregivers of individuals with TBI. These results have utility for both research and clinical applications. Establishing the TBI-CareQOL's factor structure provides preliminary evidence of the measurement system's construct validity, helps inform the selection of measures for specific research or clinical interventions, and informs the development of composite scores.

Differences in Health-Related Quality of Life after Traumatic Brain Injury between Varying Patient Groups: Sensitivity of a Disease-Specific (QOLIBRI) and a Generic (SF-36) Instrument

Factors associated with health-related quality of life (HRQOL) in patients after traumatic brain injury (TBI) include severity of initial injury, different grades of trauma recovery, sociodemographic status, and psychological characteristics. Yet, sensitivity of HRQOL instruments to such effects is often underexplored. Thus, we aimed to compare the capacity of the disease-specific QOLIBRI (Quality of Life after Brain Injury) and the generic Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey(SF-36) to detect significant differences in HRQOL between patients. Patients (n = 795) completed HRQOL, sociodemographic, clinical, psychological, and health status questionnaires. Univariate (Wilcoxon-Mann-Whitney) and multi-variate (Wei-Lachin) non-parametric analyses were conducted using the Wilcoxon-Mann-Whitney approach to compare the sensitivity of the QOLIBRI and the SF-36. For both instruments, HRQOL was particularly influenced by patients' reliance on others, depression, anxiety, and recovery status, whereas smaller effects were found for living arrangements and participation in leisure activities. Both HRQOL instruments were sensitive to group differences, but the QOLIBRI was able to detect a greater number of and finer differences between specific patient groups, which is particularly important in clinical and therapeutic contexts. This finding is likely explained by the QOLIBRI's greater specificity to disease-specific aspects of consequences of TBI. This head-to-head HRQOL instrument comparison resulted in a recommendation for the use of the QOLIBRI when detailed insight in the subjective consequences and impact of TBI on patients is required.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers

PURPOSE

To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program.

MATERIALS AND METHODS

People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement.

RESULTS

1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health.

CONCLUSIONS

LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Measuring Fatigue in TBI: Development of the TBI-QOL Fatigue Item Bank and Short Form

OBJECTIVE

To develop a traumatic brain injury (TBI)-specific, item response theory (IRT)-calibrated Fatigue item bank, short form, and computer adaptive test (CAT) as part of the Traumatic Brain Injury-Quality of Life (TBI-QOL) measurement system.

SETTING

Five TBI Model Systems rehabilitation centers in the US PARTICIPANTS:: Adults with complicated mild, moderate, or severe TBI confirmed by medical record review.

DESIGN

Cross-sectional field testing via phone or in-person interview.

MAIN MEASURES

TBI-QOL Fatigue item bank, short form, and CAT.

RESULTS

A total of 590 adults with TBI completed 95 preliminary fatigue items, including 86 items from the Patient-Reported Outcomes Measurement Information System (PROMIS) and 9 items from the Quality of Life in Neurological Disorders (Neuro-QOL) system. Through 4 iterations of factor analysis, 22 items were deleted for reasons such as local item dependence, misfit, and low item-total correlations. Graded response model IRT analyses were conducted on the 73-item set, and Stocking-Lord equating was used to transform the item parameters to the PROMIS (general population) metric. A short form and CAT, which demonstrate similar reliability to the full item bank, were developed. Test-retest reliability of the CAT was established in an independent sample (Pearson's r and intraclass correlation coefficient = 0.82 [95% confidence interval: 0.72-0.88]).

CONCLUSIONS

The TBI-QOL Fatigue item bank, short form, and CAT provide rehabilitation researchers and clinicians with TBI-optimized tools for assessment of the patient-reported experience and impact of fatigue on individuals with TBI.

Measuring Self-Reported Physical Function in Individuals With TBI: Development of the TBI-QOL Mobility and Upper Extremity Item Banks and Short Forms

OBJECTIVES

To describe the development and field testing of the patient-reported outcome measures of Mobility and Upper Extremity function from the Traumatic Brain Injury Quality of Life (TBI-QOL) measurement system, and to evaluate the use of computer adaptive testing.

SETTING

Five rehabilitation facilities funded as part of the TBI Model Systems network.

PARTICIPANTS

Individuals with complicated mild, moderate, or severe traumatic brain injury (n = 590).

INTERVENTIONS

Not available.

OUTCOME MEASURES

TBI-QOL Mobility and Upper Extremity item banks.

RESULTS

Item response theory and factor analyses supported the unidimensionality of the Mobility and Upper Extremity banks. Descriptive statistics showed a ceiling effect for both measures. Simulated computer adaptive tests (CATs) showed that measurement precision was maintained across administration formats for both measures. The Upper Extremity CAT showed a loss of precision for individuals without impairment and that a higher number of items were required to achieve sufficiently precise measurement, compared to the Mobility CAT.

CONCLUSIONS

The TBI-QOL Upper Extremity and Mobility item banks achieved good breadth of coverage, particularly among those individuals who have experienced some degree of functional limitation. The use of CAT administration minimizes respondent burden, while allowing for the comprehensive assessment of adults with TBI. The combined use of the TBI-QOL with performance-based measures could guide the development of targeted rehabilitation treatments.

Linking the GAD-7 and PHQ-9 to the TBI-QOL Anxiety and Depression Item Banks

OBJECTIVE

To link scores on commonly used measures of anxiety (7-item Generalized Anxiety Disorder Scale; GAD-7) and depression (9-item Patient Health Questionnaire; PHQ-9) to the Traumatic Brain Injury Quality of Life (TBI-QOL) measurement system.

SETTING

5 Traumatic Brain Injury Model Systems.

PARTICIPANTS

A total of 385 individuals with traumatic brain injury (TBI) (31% complicated mild; 14% moderate; and 54% severe).

DESIGN

Observational cohort.

MAIN MEASURES

GAD-7, PHQ-9, TBI-QOL Anxiety v1.0 and TBI-QOL Depression v1.0.

RESULTS

Item response theory-based linking methods were used to create crosswalk tables that convert scores on the GAD-7 to the TBI-QOL Anxiety metric and scores on the PHQ-9 to the TBI-QOL Depression metric. Comparisons between actual and crosswalked scores suggest that the linkages were successful and are appropriate for group-level analysis. Linking functions closely mirror crosswalks between the GAD-7/PHQ-9 and the Patient-Reported Outcomes Measurement Information System (PROMIS), suggesting that general population linkages are similar to those from a TBI sample.

CONCLUSION

Researchers and clinicians can use the crosswalk tables to transform scores on the GAD-7 and the PHQ-9 to the TBI-QOL metric for group-level analyses.

Development and Psychometric Characteristics of the TBI-QOL Independence Item Bank and Short Form and the TBI-QOL Asking for Help Scale

OBJECTIVE

To develop an item response theory (IRT)-calibrated, patient-reported outcome measure of subjective independence for individuals with traumatic brain injury (TBI).

DESIGN

Large-scale item calibration field testing; confirmatory factor analysis (CFA) and graded response model IRT analyses.

SETTING

Five TBI Model System centers across the United States.

PARTICIPANTS

Adults with complicated mild, moderate, or severe TBI (N=556).

OUTCOME MEASURES

Traumatic Brain Injury-Quality of Life (TBI-QOL) Independence item bank and the TBI-QOL Asking for Help scale.

RESULTS

A total of 556 individuals completed 44 items in the Independence item pool. Initial factor analyses indicated that items related to the idea of "asking for help" were measuring a different construct from other items in the pool. These 9 items were set aside. Twenty-two other items were removed because of bimodal distributions and/or low item-total correlations. CFA supported unidimensionality of the remaining Independence items. Graded response model IRT analysis was used to estimate slopes and thresholds for the final 13 Independence items. An 8-item fixed-length short form was also developed. The 9 Asking for Help items were analyzed separately. One misfitting item was deleted, and the final 8 items became a fixed-length IRT-calibrated scale. Reliability was high for both measures.

CONCLUSIONS

The IRT-calibrated TBI-QOL Independence item bank and short form and TBI-QOL Asking for Help scale may be used to measure important issues for individuals with TBI in research and clinical applications.

The relationship between resilience, emotional distress, and community participation outcomes following traumatic brain injury

Purpose/Objective: To determine how resilience is associated with social participation outcomes in persons with traumatic brain injury (TBI), in the context of emotional distress, demographics, and injury-related factors.Setting: Individuals with a history of TBI recruited the following stay at three rehabilitation facilities in the USA.Participants: 201 community-dwelling persons with medically documented TBI ranging in severity from mild to severe.Design: Prospective cohort observational study. Data were collected at two time points, approximately 6 months apart.Main Measures: TBI-QOL; PART-OResults: Resilience at baseline was moderately to strongly correlated with baseline psychological distress variables (r_s= -.66) and social participation variables (r_s =.33 to.57). In regression analyses, resilience was directly associated with social participation outcomes and formed a significant interaction with emotional distress in some models. Resilience failed to show a relationship with social participation at 6-month follow-up, when controlling for baseline social participation.Conclusions: Though related to emotional distress, self-reported resilience makes a unique contribution to predicting outcomes over time following brain injury, and may impact the relationship between stress and negative participation outcomes. As such, it is possible interventions that promote resilience may mitigate distress and promote community integration.

Traumatic Brain Injury Modifies the Relationship Between Physical Activity and Global and Cognitive Health: Results From the Barcelona Brain Health Initiative

Physical activity has many health benefits for individuals with and without history of brain injury. Here, we evaluated in a large cohort study the impact of physical activity on global and cognitive health as measured by the PROMIS global health and NeuroQoL cognitive function questionnaires. A nested case control study assessed the influence of a history of traumatic brain injury (TBI) on the effects of physical activity since underlying pathophysiology and barriers to physical activity in individuals with TBI may mean the effects of physical activity on perceived health outcomes differ compared to the general population. Those with a history of TBI (n = 81) had significantly lower Global health (β = -1.66, p = 0.010) and NeuroQoL cognitive function (β = -2.65, p = 0.006) compared to healthy adults (n = 405). A similar proportion of individuals in both groups reported being active compared to being insufficiently active (X ( 1 ) 2 = 0.519 p = 0.471). Furthermore, the effect of physical activity on global health (β = 0.061, p = 0.076) and particularly for NeuroQoL (β = 0.159, p = 0.002) was greater in those with a history of TBI. Individuals with a history of TBI can adhere to a physically active lifestyle, and if so, that is associated with higher global and cognitive health perceptions. Adhering to a physically active lifestyle is non-trivial, particularly for individuals with TBI, and therefore adapted strategies to increase participation in physical activity is critical for the promotion of public health.

Perceptions of the impact of chorea on health-related quality of life in Huntington disease (HD): A qualitative analysis of individuals across the HD spectrum, family members, and clinicians

Chorea, a hallmark symptom of Huntington's disease (HD), is characterized by jerky involuntary movements affecting the whole body that can interfere with daily functioning and impact health-related quality of life (HRQOL). To characterize chorea's impact on everyday functioning and HRQOL and identify patterns of perception and experiences of chorea among patients, caregivers, and providers. Data from focus groups of individuals with manifest HD (n = 8 early-stage HD; n = 16 late-stage HD), individuals at-risk or prodromal HD (n = 16), family HD caregivers (n = 17), and HD clinicians (n = 25). Focus group recordings were transcribed verbatim and analysed via constant comparison to identify meaningful and salient themes of living with chorea. Global themes of chorea's impact identified included: watching for chorea, experiences of stigma, and constraints on independence and relationships. Themes distinct to specific respondent groups included: Vigilance (at risk, prodromal); adaptation to chorea (early-stage); loss of autonomy and social life (late-stage); monitoring engagement (family caregivers) and safety (clinical providers). Living with chorea significantly constrains daily functioning, interactions, and HRQOL across the HD disease spectrum. Addressing these impacts via appropriate management of chorea can potentially enhance functioning, HRQOL, and overall satisfaction for persons with HD and their families.

Reliability and Construct Validity of the TBI-QOL Communication Short Form as a Parent-Proxy Report Instrument for Children With Traumatic Brain Injury

Purpose The purpose of this study was to evaluate the internal consistency and construct validity of the Traumatic Brain Injury Quality of Life Communication Item Bank (TBI-QOL COM) short form as a parent-proxy report measure. The TBI-QOL COM is a patient-reported outcome measure of functional communication originally developed as a self-report measure for adults with traumatic brain injury (TBI), but it may also be valid as a parent-proxy report measure for children who have sustained TBI. Method One hundred twenty-nine parent-proxy raters completed the TBI-QOL COM short form 6 months postinjury as a secondary aim of a multisite study of pediatric TBI outcomes. The respondents' children with TBI were between 8 and 18 years old ( M _age = 13.2 years old) at the time of injury, and the proportion of TBI severity mirrored national trends (73% complicated-mild; 27% moderate or severe). Results The parent-proxy report version of the TBI-QOL COM displayed strong internal consistency (ordinal α = .93). It also displayed evidence of known-groups validity by virtue of more severe injuries associated with more abnormal scores. The instrument also showed evidence of convergent and discriminant validity by displaying a pattern of correlations with other constructs according to their conceptual relatedness to functional communication. Conclusions This preliminary psychometric investigation of the TBI-QOL COM supports the further development of a parent report version of the instrument. Future development of the TBI-QOL COM with this population may include expanding the content of the item bank and developing calibrations specifically for parent-proxy raters. Supplemental Material https://doi.org/10.23641/asha.7616534.

The factor structure of the Quality of Life Inventory (QOLI) following traumatic brain injury

Quality of life is a key indicator of outcome following traumatic brain injury (TBI). Research has reported several different factor structures for the Quality of Life Inventory (QOLI, Frisch, 1994). We compared the fit of existing factor models and examined the clinical utility of the QOLI's factors in a sample of Australian adults with TBI. Archival data from 901 participants were provided by the Neurotrauma Register of Tasmania. Participants were aged 16-80 years and 63% were male. Approximately 69% had mild TBI (PTA < 24 h), approximately 24% had moderate TBI (PTA >1 day, <7 days) and 7% had severe TBI. Both cross sectional and longitudinal analyses were utilized, as participants provided data at one or more of seven time-points, up to 3 years following injury. The results showed the data best fitted a three-factor model, comprising Self-functioning and activity, Self-actualization and Family and environment factors, and a second order Overall QOL factor. Differences in the trajectory of recovery were noted between the QOLI factor scores over time and in relation to demographic and injury variables. In conclusion, the three-factor structure of the QOLI provided useful clinical information about the recovery of patients' subjective quality of life following TBI.

Caring for an individual with mild cognitive impairment: a qualitative perspective of health-related quality of life from caregivers

OBJECTIVES

Little is known regarding the effect that caring for an individual with Mild Cognitive Impairment (MCI) has on health-related quality of life (HRQOL). We sought to identify the most important aspects of HRQOL related to caring for an individual with MCI.

METHODS

Six focus groups were conducted with caregivers of individuals with MCI (n = 32). Qualitative frequency analysis was used to analyze the data.

RESULTS

Findings indicated that caregivers most frequently discussed social health, including changes in social roles and an increased need for social support (51.2% of the total discussion). This was followed by mental health concerns (37.9%) centering on anger/frustration, and a need for patience in the caregiving role, as well as caregiver-specific anxiety. Other topics included physical health (10.0%; including the impact that stress and burden have on medical heath), and caregivers' cognitive health (0.9%; including memory problems in relation to caregiver strain, sleep disruption, and cognitive fatigue).

CONCLUSIONS

Findings illustrate the multiple domains of HRQOL that are affected in individuals providing care for someone with MCI. Moreover, the findings highlight the need for extending support services to MCI caregivers, a group that is typically not offered support services due to the 'less severe' nature of an MCI diagnosis.

Validating the Quality of Life After Brain Injury Through Rasch Analysis

OBJECTIVE

The Quality of Life after Brain Injury (QOLIBRI), a cross-cultural instrument, has been validated in several languages; however, traditional psychometric approaches have critical limitations. Therefore, we applied the Rasch model for validating the 37-item QOLIBRI scale among a Chinese population with traumatic brain injury.

PARTICIPANTS AND SETTING

In total, 587 participants (mean age: 44.2 ± 15.4 years; women, 46.3%) were surveyed in neurosurgery departments at 6 hospitals in Taipei, Taiwan.

MAIN OUTCOME MEASURE

The QOLIBRI.

RESULTS

Of the 6 subscales of the QOLIBRI, 4 (cognition, self, daily life and autonomy, and social relationships) were unidimensional, valid, and reliable, whereas the remaining 2 (emotions and physical problems) exhibited poor unidimensionality, item and person reliability, and person-item targeting. Five items (energy, concentrating, getting out and about, sex life, and achievements) showed considerable differential item functioning among age groups, disability levels, and time since traumatic brain injury.

CONCLUSION

According to item response theory, we identified psychometric issues in the emotions and physical problems subscales of the QOLIBRI as well as several differential item functioning items. Future research is required to determine whether similar results are observed in other language versions of the QOLIBRI or in other countries.