Prediction of global outcome with acute neuropsychological testing following closed-head injury

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Behavioral Phenotyping

BACKGROUND

The recent publication of practice guidelines for management of patients with disorders of consciousness (DoC) in the United States and Europe was a major step forward in improving the accuracy and consistency of terminology, diagnostic criteria, and prognostication in this population. There remains a pressing need for a more precise brain injury classification system that combines clinical semiology with neuroimaging, electrophysiologic, and other biomarker data. To address this need, the National Institute of Neurological Disorders and Stroke launched the Common Data Elements (CDEs) initiative to facilitate systematic collection of high-quality research data in studies involving patients with neurological disease. The Neurocritical Care Society's Curing Coma Campaign expanded this effort in 2018 to develop CDEs for DoC. Herein, we present CDE recommendations for behavioral phenotyping of patients with DoC.

METHODS

The Behavioral Phenotyping Workgroup used a preestablished, five-step process to identify and select candidate CDEs that included review of existing National Institute of Neurological Disorders and Stroke CDEs, nomination and systematic vetting of new CDEs, CDE classification, iterative review, and approval of panel recommendations and development of corresponding case review forms.

RESULTS

We identified a slate of existing and newly proposed basic, supplemental, and exploratory CDEs that can be used for behavioral phenotyping of adult and pediatric patients with DoC.

CONCLUSIONS

The proposed behavioral phenotyping CDEs will assist with international harmonization of DoC studies and allow for more precise characterization of study cohorts, favorably impacting observational studies and clinical trials aimed at improving outcome in this population.

Mood Tracker: A Randomized Controlled Trial of a Self-Monitoring Intervention for Emotional Distress After Traumatic Brain Injury

OBJECTIVE

Persons with traumatic brain injury (TBI) frequently experience emotional distress (ED) manifested in anxiety and depression. However, they may not access mental health services due to external (eg, access, transportation, and cost) or internal (eg, stigma and discomfort with traditional counseling) barriers. Based on substantial literature indicating that self-monitoring can ameliorate several health conditions, we conducted a randomized, parallel group, wait-list control (WLC) trial of a self-monitoring intervention to decrease ED after TBI.

SETTING

Community in the southwestern United States.

PARTICIPANTS

Persons with medically documented complicated mild, moderate, and severe TBI.

DESIGN

About 127 participants were randomized in blocks of 6 to an active treatment (AT) group, wherein they completed multiple assessments of ED each week over a 6-week period via a smartphone app, or a WLC group in a parallel group, controlled trial. Participants received weekly support calls to promote self-monitoring of ED using ecological momentary assessment.

MAIN MEASURES

ED (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), Satisfaction with Life Scale, and Participation Assessment with Recombined Tools-Objective.

RESULTS

Analysis of the primary study outcome at 6 weeks after initiation of treatment for the AT group did not demonstrate that self-monitoring was effective in decreasing ED as compared to the WLC group. Brief support calls made weekly to promote compliance with self-monitoring were effective in achieving the target number of self-assessments. About 80% of support calls lasted less than 5 minutes. Greater ED was associated with lower life satisfaction and lower participation indicating the importance of addressing ED in persons with TBI.

CONCLUSION

Additional work is needed to develop nontraditional interventions to circumvent barriers that prevent persons with TBI from accessing care for ED. Brief support calls may be an effective, low-cost intervention to improve compliance with self-monitoring or self-management interventions.

Feasibility and Utility of a Flexible Outcome Assessment Battery for Longitudinal Traumatic Brain Injury Research: A TRACK-TBI Study

The effects of traumatic brain injury (TBI) are difficult to measure in longitudinal cohort studies, because disparate pre-injury characteristics and injury mechanisms produce variable impairment profiles and recovery trajectories. In preparation for the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, which followed patients with injuries ranging from uncomplicated mild TBI to coma, we designed a multi-dimensional Flexible outcome Assessment Battery (FAB). The FAB relies on a decision-making algorithm that assigns participants to a Comprehensive (CAB) or Abbreviated Assessment Battery (AAB) and guides test selection across all phases of recovery. To assess feasibility of the FAB, we calculated the proportion of participants followed at 2 weeks (2w) and at 3, 6, and 12 months (3m, 6m, 12m) post-injury who completed the FAB and received valid scores. We evaluated utility of the FAB by examining differences in 6m and 12m Glasgow Outcome Scale-Extended (GOSE) scores between participant subgroups derived from the FAB-enabled versus traditional approach to outcome assessment applied at 2w. Among participants followed at 2w (n = 2094), 3m (n = 1871), 6m (n = 1736), and 12m (n = 1607) post-injury, 95-99% received valid completion scores on the FAB, in full or in part, either in person or by telephone. Level of function assessed by the FAB-enabled approach at 2w was associated with 6m and 12m GOSE scores (proportional odds p < 0.001). These findings suggest that the participant classification methodology afforded by the FAB may enable more effective data collection to improve detection of natural history changes and TBI treatment effects.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

The ecological validity of the Uniform Data Set 3.0 neuropsychological battery in individuals with mild cognitive impairment and dementia

Objective: Ecological validity refers to the ability of neuropsychological measures to predict real world performance. Questions remain as to the ecological validity of commonly used measures, particularly regarding their relationships to global versus specific activities of daily living among those with neurodegenerative disease. We explored these issues through the lens of the Uniform Data Set 3.0 Neuropsychological battery (UDS3NB) in individuals with mild cognitive impairment and dementia. Method: UDS3NB and informant rated Functional Activities Questionnaire scales were evaluated from 2,253 individuals with mild cognitive impairment and dementia. Ordinal regression equations were used to explore the relationships of demographic and cognitive variables with overall and specific instrumental activities of daily living. Results: Delayed recall for visual and verbal material, and performance on trail making tests were consistent predictors of global and specific functions. Specific skills (i.e. naming or figure copy) showed differential relationships with specific activities, while phonemic fluency was not related to any particular activity. Conclusions: Measures in the UDS3NB predicted activities of daily living in individuals with MCI and dementia, providing initial support for the ecological validity of these tests. Specifically, measures that tap core deficits of Alzheimer's disease, such as delayed recall and sequencing/shifting, are consistent predictors of performance in daily tasks.

How impaired is too impaired? Exploring futile neuropsychological test patterns as a function of dementia severity and cognitive screening scores

Some older adults cannot meaningfully participate in the testing portion of a neuropsychological evaluation due to significant cognitive impairments. There are limited empirical data on this topic. Thus, the current study sought to provide an operational definition for a futile testing profile and examine cognitive severity status and cognitive screening scores as predictors of testing futility at both baseline and first follow-up evaluations. We analysed data from 9,263 older adults from the National Alzheimer's Coordinating Center Uniform Data Set. Futile testing profiles occurred rarely at baseline (7.40%). There was a strong relationship between cognitive severity status and the prevalence of futile testing profiles, χ² (4) = 3559.77, p < .001. Over 90% of individuals with severe dementia were unable to participate meaningfully in testing. Severity range on the Montreal Cognitive Assessment (MoCA) also demonstrated a strong relationship with testing futility, χ² (3) = 3962.35, p < .001. The rate of futile testing profiles was similar at follow-up (7.90%). There was a strong association between baseline dementia severity and likelihood of demonstrating a futile testing profile at follow-up, χ² (4) = 1513.40, p < .001. Over 90% of individuals with severe dementia, who were initially able to participate meaningfully testing, no longer could at follow-up. Similarly, there was a strong relationship between baseline MoCA score band and likelihood of demonstrating a futile testing profile at follow-up, χ² (3) = 1627.37, p < .001. Results can help to guide decisions about optimizing use of limited neuropsychological assessment resources.

Soy diferente: a qualitative study on the perceptions of recovery following traumatic brain injury among Spanish-speaking U.S. immigrants

PURPOSE

To explore the impact of traumatic brain injury (TBI) on the quality of life (QoL) and self-concept of Spanish-speaking U.S. Hispanic immigrants with TBI.

MATERIALS AND METHODS

A prospective, qualitative study conducted in a county level I trauma center and community. Semi-structured interviews on QoL and self-concept following TBI were conducted with 24 Spanish-speaking U.S. Hispanic immigrants with TBI living in the community at least 6 months following injury.

RESULTS

Perceived facilitators of QoL included faith, hopefulness in recovery, empathy for others, and support from others. Perceived barriers to QoL mentioned were symptoms/consequences of injury, employment/financial changes, loss of independence, fear/uncertainty, stigma/shame, lack of medical care, and decreased social integration. Participants described their self-concept after TBI as either a maintained self or loss of self. Those who viewed themselves differently reported physical and emotional changes, gender role conflict, loss of self-worth, and total loss due to the TBI.

CONCLUSIONS

Spanish-speaking U.S. Hispanic immigrants held a strong faith and positive outlook after TBI in spite of the significant barriers to recovery. A need exists for programs to support creatively the recovery of Spanish-speaking U.S. Hispanic immigrants with limited access to care and resources.IMPLICATIONS FOR REHABILITATIONSpanish-speaking U.S. Hispanic immigrants may experience significant barriers to care following traumatic brain injury (TBI), such as access to rehabilitation services and follow-up care.Rehabilitation professionals should consider the importance of faith and encourage positive thinking and social support when working with Spanish-speaking U.S. Hispanic immigrants on how to cope with TBI-related challenges.Access to Spanish-speaking rehabilitation professionals, translators and Spanish language educational materials could help reduce language-related barriers to recovery among Spanish-speaking U.S. immigrants with TBI.Rehabilitation facilities should develop partnerships with community-based organizations serving the uninsured or underinsured to address the access to rehabilitation and medical needs of Spanish-speaking U.S. immigrants with TBI.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Patterns of narrative discourse in early recovery following severe Traumatic Brain Injury

Primary Objective: To investigate the nature and patterns of narrative discourse impairment in people with severe Traumatic Brain Injury (TBI) during early recovery.Methods and Procedures: A single image picture description task was administered to 42 participants with severe TBI at 3 and 6-months post-injury. The same task was administered to 37 control participants. Discourse samples were analyzed with measures of productivity, informativeness and story organization. The performance of people with TBI was compared with the control group at both 3 and 6 months, and the performance of the participants with TBI was also compared across the two time points. Individual patterns of performance were also examined.Results: Inferential analyses revealed significant differences between the control group and the group with TBI on informativeness at both time points and  number of complete episodes at 3 months, but no significant differences for productivity measures. There was no significant change for the group with TBI between 3 and 6 months. However, individual improvement over time was observed.Conclusions: People with TBI have discourse difficulties early post TBI that are also present at 6-months post-injury. In order to understand longer-term discourse recovery, it is necessary to examine participant patterns over further time points on this narrative task.

The incremental value of neuropsychological assessment: A critical review

Objective: The purpose of this critical review was to evaluate the current state of research regarding the incremental value of neuropsychological assessment in clinical practice, above and beyond what can be accounted for on the basis of demographic, medical, and other diagnostic variables. The focus was on neurological and other medical conditions across the lifespan where there is known risk for presence or future development of cognitive impairment.Method: Eligible investigations were group studies that had been published after 01/01/2000 in English in peer-reviewed journals and that had used standardized neuropsychological measures and reported on objective outcome criterion variables. They were identified through PubMed and PsychInfo electronic databases on the basis of predefined specific selection criteria. Reference lists of identified articles were also reviewed to identify potential additional sources. The Grades of Recommendation, Assessment, Development and Evaluation Working Group's (GRADE) criteria were used to evaluate quality of studies.Results: Fifty-six studies met the final selection criteria, including 2 randomized-controlled trials, 9 prospective cohort studies, 12 retrospective cohort studies, 21 inception cohort studies, 2 case control studies, and 10 case series studies. The preponderance of the evidence was strongly supportive with regard to the incremental value of neuropsychological assessment in the care of persons with mild cognitive impairment/dementia and traumatic brain injury. Evidence was moderately supportive with regard to stroke, epilepsy, multiple sclerosis, and attention-deficit/hyperactivity disorder. Participation in neuropsychological evaluations was also associated with cost savings.Conclusions: Neuropsychological assessment can improve both diagnostic classification and prediction of long-term daily-life outcomes in patients across the lifespan. Future high-quality prospective cohort studies and randomized-controlled trials are necessary to demonstrate more definitively the incremental value of neuropsychological assessment in the management of patients with various neurological and other medical conditions.

Prediction of behavioural and cognitive deficits in patients with traumatic brain injury at an acute rehabilitation setting

OBJECTIVE

The goal of this study was to identify factors that would predict short-term neuropsychological outcome in patients with traumatic brain injury (TBI) hospitalized in an acute rehabilitation setting.

METHODS

Data was collected in the context of an acute early rehabilitation setting of a trauma centre. A brief neuropsychological assessment was carried out for 348 patients within a month following their trauma.

RESULTS

Length of post-traumatic amnesia (PTA) was the best predictor of behavioural, memory and executive function variables within a month post TBI. The odds of being agitated, labile, irritable and disinhibited at one month post trauma were almost six times higher for those with PTA that lasted more than 7 days compared to those with a PTA of less than 24 hours. Also, the odds of having a higher mental manipulation score (less significant executive function impairment) were almost two times lower for those with frontal lesions, and three to six times lower for those with PTA of more than 24 hours. In addition, TBI severity, education and age were considered good predictors of some aspects of neuropsychological outcome.

CONCLUSION

This model may help clinicians and administrators recognize the probable post-traumatic deficits as quickly as possible and to plan interventions as well as post-acute discharge orientation accordingly and early on.

Neuropsychological assessment without upper limb involvement: a systematic review of oral versions of the Trail Making Test and Symbol-Digit Modalities Test

The Trail Making Test (TMT) and written version of the Symbol Digit Modalities Test (SDMT) assess attention, processing speed, and executive functions but their utility is limited in populations with upper limb dysfunction. Oral versions of the TMT and SDMT exist, but a systematic review of their psychometric properties and clinical utility has not been conducted, which was the goal of this study. Searches were conducted in PubMed and PsycINFO, test manuals, and the reference lists of included articles. Four measures were identified: the SDMT-oral, oral TMT-A, oral TMT-B, and the Mental Alternation Test (MAT). Two investigators independently reviewed abstracts to identify peer-reviewed articles that reported on these measures in adult populations. From each article, one investigator extracted information on reliability, validity, responsiveness, minimum detectable change, normative data, and demographic influences. A second investigator verified the accuracy of the data in a random selection of 10% of papers. The quality of the evidence for each psychometric property was rated on a 4-point scale (unknown, poor, adequate, excellent). Results showed excellent evidence for the SDMT-oral, adequate evidence for the oral TMT-B and MAT, and adequate to poor evidence for the oral TMT-A. These findings inform the clinical assessment of attention, processing speed, and executive functions in individuals with upper limb disability.

Influence of alcohol on early Glasgow Coma Scale in head-injured patients

BACKGROUND

To assess the depressant effects of alcohol on the level of consciousness of patients admitted with head injuries, this study examined the changes that occur in the Glasgow Coma Scale (GCS) of traumatic brain injury patients over time.

METHODS

The records of 269 head trauma patients consecutively admitted to the neurosurgery intensive care unit were examined retrospectively. Eighty-one patients were excluded because of incomplete data. The remaining 188 patients were further divided into an intoxicated group (blood alcohol concentration [BAC] ≥ 0.08%, n = 100 [53%]) and a nonintoxicated group (BAC <0.08%, n = 88 [47%]). The GCS in the prehospital setting, in the emergency department, and the highest GCS achieved during the first 24 hours postinjury were compared.

RESULTS

The change between emergency department-GCS and the best day 1 GCS in the intoxicated group was greater than the nonintoxicated group and deemed clinically and statistically significant; median change (3 vs. 0) p < 0.001. To assess whether these results were directly related to the BAC%, piecewise regression using a general linear model was used to assess the intercept and slope of alcohol on the changes of GCS with cutting point at BAC% = 0.08. The analysis showed that, in the nonintoxicated range, the effect of alcohol was not significantly related to the changes of GCS. But in the intoxicated range, BAC% was significantly positively related to the changes of GCS.

CONCLUSION

This study concludes that the GCS increases significantly over time in alcohol intoxicated patients with traumatic brain injury.

Galveston Orientation Amnesia Test (GOAT)

O trauma crânio-encefálico contuso (TCEC) é freqüentemente seguido pela amnésia pós-traumática (APT), caracterizada como um estado transitório de confusão e desorientação. Sua duração tem sido utilizada para quantificar a gravidade do TCEC e prever distúrbios nas funções cognitivas, assim como para antever as alterações na capacidade funcional das vítimas pós-trauma. O Galveston Orientation Amnesia Test (GOAT) é o primeiro instrumento sistematizado criado e o mais amplamente utilizado para avaliar a APT. Este artigo apresenta esse instrumento, as bases conceituais para seu desenvolvimento e a adaptação e validação do GOAT para cultura brasileira. Além disso, descreve sua aplicação e comenta as restrições do seu uso. Resultados de pesquisas realizadas em nosso meio contribuíram para as evidências sobre a validade do GOAT. Também apontaram os indicadores do momento pós-trauma em que o GOAT deve ser aplicado e destacaram as dificuldades no uso desse instrumento.

Using the assessment of motor and process skills to measure functional change in adults with severe traumatic brain injury: A pilot study

AIM

To measure functional change in 10 adults following severe traumatic brain injury using the Assessment of Motor and Process Skills (AMPS).

METHODS

This clinical pilot study used a standardised occupational therapy tool, the AMPS, to measure motor and process scores during activities of daily living, for over 3 weeks of inpatient rehabilitation.

RESULTS

Wilcoxon signed ranks tests indicate significant improvement in motor and process scores from initial assessment to repeat evaluation (z = -2.70, p = 0.01; z = -2.81, P = 0.01, respectively).

CONCLUSIONS

The AMPS measured statistically and clinically significant change in motor and process abilities over 3 weeks of neurosurgical rehabilitation. Findings suggest that the AMPS is a sensitive measure of functional change for the study sample and timeframe.

The predictive validity of a brief inpatient neuropsychologic battery for persons with traumatic brain injury

OBJECTIVE

To examine the predictive validity of a brief neuropsychologic test battery consisting of the Galveston Orientation and Amnesia Test, the California Verbal Learning Test-II, Trail-Making Test (TMT), Symbol Digit Modalities Test, grooved pegboard, phonemic and categorical word generation tasks, the Wechsler Test of Adult Reading (WTAR), and the Wisconsin Card Sorting Test-64 relative to functional outcome at 1 year in persons with traumatic brain injury.

DESIGN

Inception cohort study. Follow-up period of 12 months.

SETTING

Seven Traumatic Brain Injury Model System centers. Neuropsychologic testing was conducted during the acute inpatient rehabilitation stay and functional outcome measures were obtained at 1-year outpatient follow-up.

PARTICIPANTS

Adults (N=174) who met criteria for admission to inpatient brain injury rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM instrument, Disability Rating Scale, Supervision Rating Scale, Satisfaction With Life Scale (SWLS), and Glasgow Outcome Scale-Extended.

RESULTS

Multiple regression analyses revealed that performance on the neuropsychologic test battery was predictive of outcome at 1 year postinjury for all outcome measures, except FIM motor scores and the SWLS. Cognitive performance using this battery was found to predict 1-year outcomes above and beyond functional variables and injury severity variables collected during inpatient rehabilitation, thereby indicating incremental validity for this test battery. Individual tests that were found to be significant predictors of 1-year outcomes included the WTAR and TMT part B.

CONCLUSIONS

These findings support the clinical utility and ecological validity of this battery with respect to level of disability, functional independence, and supervision required.

Galveston Orientation and Amnesia Test: applicability and relation with the Glasgow Coma Scale

Restrictions in the application of the Galveston Orientation and Amnesia Test and questionings about the relationship between conscience and post-traumatic amnesia motivated this study, which aims to identify, through the Glasgow Coma Scale scores, when to initiate the application of this amnesia test, as well to verify the relationship between the results of these two indicators. The longitudinal prospective study was carried at a referral center for trauma care in São Paulo - Brazil. The sample consisted of 73 victims of blunt traumatic brain injury, admitted at this institution between January 03rd and May 03rd 2001. Regarding the applicability, the test could be applied in patients with a Glasgow Coma Scale score > 12; however, the end of post traumatic amnesia was verified in patients who scored > 14 on the scale. A significant relationship (r s = 0.65) was verified between these measures, although different kinds of relationship between the end of the amnesia and changes in consciousness were observed.

"Galveston Orientation and Amnesia Test": tradução e validação

OBJETIVO: Traduzir e validar o Galveston Orientation and Amnesia Test para uso em nosso meio. MÉTODOS: Esse teste foi traduzido para o português e retro-traduzido para o inglês por diferentes especialistas na língua e por fim, feita a avaliação da equivalência entre o instrumento original e a versão retro-traduzida. Sua aplicação em 73 vítimas de trauma crânio-encefálico contuso e a indicação da gravidade dessa lesão, estabelecida pela Escala de Coma de Glasgow, permitiram verificar as propriedades de medida do instrumento. RESULTADOS: A confiabilidade verificada pelo Alfa de Cronbach resultou em 0,76. Houve indicação de validade convergente e discriminante do instrumento quando os resultados de aplicação do Galveston Orientation and Amnésia Test foram analisados perante a gravidade do trauma crânio-encefálico. CONCLUSÃO: Os resultados observados dão suporte para a aplicação do Galveston Orientation and Amnesia Test em nosso meio como indicador do término da amnésia pós-traumática.

Early Versus Later Admission to Postacute Rehabilitation: Impact on Functional Outcome After Traumatic Brain Injury

OBJECTIVE

To examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI).

DESIGN

Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design.

SETTING

Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital.

PARTICIPANTS

Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29).

INTERVENTIONS

Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community.

MAIN OUTCOME MEASURES

Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire.

RESULTS

All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge.

CONCLUSIONS

The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.