Application of functional independence measure in the rehabilitation of military servicemen wounded during war operations in Ukraine.

In the structure of military traumatism, the number of multiple and combined wounds and injuries has increased significantly due to the expansion in the destructive properties of modern weapons. Establishing the correct rehabilitation diagnosis and subsequent stage-by-stage assessment of the results of rehabilitation therapy should be based on adequate functional assessment tools. The Barthel Index is the most widely used measure for assessing the ability to perform activities of daily living. However, recently, many authors have proposed using the Functional Independence Measure (FIM) for this purpose. Purpose. The study aims to investigate the possibility of using the Barthel Index and Functional Independence Measure to assess the effectiveness of rehabilitation of military personnel with combined injuries over a long period. Material & Methods. We conducted a retrospective study of 807 wounded military personnel with complex injuries of varying severity. Our examination included a meticulous analysis of medical records, a comprehensive physical examination, and a survey using the Barthel Index and FIM scale. Due to the nature of the injuries, the servicemen were provided with standard rehabilitation programs. Results. All patients were classified as lightly injured and moderately injured according to the Abbreviated Injury Scale. The initial data in evaluating functioning on the FIM scale made it possible to identify subgroups of patients with a predominance of motor function impairment and a predominant impairment of cognitive functions. Patients with combined TBI should receive more rehabilitation measures to improve cognitive and mental functions, socialization, and communication skills. Conclusions. The inclusion of the FIM scale in the recommended toolkit for assessing the effectiveness of rehabilitation will allow for additional objectification of rehabilitation care and the formulation of individual recommendations for achieving the best results.

Blast Injury Basics

Objective: Traumatic brain injury (TBI) is a global public health problem. Hyperbaric oxygen (HBO) therapy may be beneficial for TBI because it improves cerebral blood flow into tissues exhibiting low blood flow. This was done to observe the clinical therapeutic effect of different intensities of rehabilitation training and HBO therapy in early stages of TBI.Approach: In this multicenter, randomized, stratified case-controlled prospective clinical trial, we selected 158 patients with moderate-severe TBI and assigned them into (1) a control group receiving routine once-daily (1/d) rehabilitation training without HBO, (2) study group A receiving routine 1/d rehabilitation training with HBO, (3) study group B receiving twice-daily (2/d) intensified rehabilitation training with HBO, and (4) study group C receiving 2/d intensified rehabilitation training without HBO, all for 3 months. The cognitive ability, activities of daily life (ADL), and movement ability were assessed before and after training with the Fugl-Meyer Assessment (FMA), Functional Independence Measure (FIM), Modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE).Results: FIM, FMA, MBI, and MMSE scores were improved significantly after 1-, 2-, and 3-month rehabilitation training in all TBI patients (p < 0.01), and this improvement was especially remarkable in patients who received 2/d intensified rehabilitation training with HBO (p < 0.01).Innovation: With extensive and intensive research on TBI rehabilitation, it was proved that TBI rehabilitation intervention should be initiated as early as possible.Conclusion: Early intensified rehabilitation training in combination with HBO is more beneficial to the recovery of cognitive, ADL, and movement abilities of TBI patients.

Objective: The characteristics of the Disability Rating Scale (DRS), Functional Independence Measure (FIM), Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and Community Integration Questionnaire (CIQ) are examined, especially in regard to a “celling effect” after rehabilitation discharge (ie, how well each of the instruments detects meaningful change in level of function). Design: Data were collected prospectively at admission and discharge from acute inpatient rehabilitation and at years 1 and 2 after injury (the CIQ was collected only at years 1 and 2). Analyses are reported on a subsamplc of cases with listwise deletion, although the analyses were also done using all data available, and results compared to ensure stability of findings between samples. Setting: National database of the four Traumatic Brain Injury (TBI) Model Systems in San Jose, Calif; Detroit, Mich; Richmond, Va; and Houston, Tex. Patients: All consenting patients with TBI age 16 and older admitted to a Model System within 24 hours of Injury and receiving inpatient rehabilitation within the Model System qualified for the study. Data on 612 individuals were collected, with a minimum of 80 cases having complete data over time. Main Outcome Measures: The DRS, FIM, FIM+FAM, and CIQ. Results: There is a substantial ceiling effect of the FIM, even by inpatient rehabilitation discharge (ie, one half of the cases have an average score of 6 to 7 [“independent or modified independence—no helper] across the 18 FIM Items). The FIM+FAM shows a ceiling effect In one third of the cases. The DRS shows less ceiling effect at discharge, 1 year, and 2 years than the FIM or the FIM+FAM. CIQ scores have a ceiling effect on home and social integration subscales when compared with scores from a sample of individuals without disabilities. The productivity subscale remains well below the norm. Conclusions: Celling effects for the FIM, FIM+FAM, and two of the three CIQ subscales indicate that these measures are not as sensitive to changes, especially in the community, as may be needed to assess progress in areas most commonly causing dysfunction for the TBI population. More emphasis must be placed on improved measurement of relevant goals in the postacute and home settings with brief and precise scales

Treatment of combined traumatic brain injury and hemorrhagic shock, poses a particular challenge due to the possible conflicting consequences. While restoring diminished volume is the treatment goal for hypovolemia, maintaining adequate cerebral perfusion pressure and avoidance of secondary damage remains a treatment goal for the injured brain. Various treatment modalities have been proposed, but the optimal resuscitation fluid and goals have not yet been clearly defined. A growing body of evidence suggests that in hypovolemic shock, resuscitation with fresh whole blood (FWB) may be superior to component therapy without platelets (which are likely to be unavailable in the pre-hospital setting). Nevertheless, the effects of this approach have not been studied in the combined injury. Previously, in a rat model of combined injury we have found that mild resuscitation to MABP of 80mmHg with FWB is superior to fluid resuscitation or aggressive resuscitation with FWB. In this study, we investigate the physiological and neurological outcomes in a rat model of combined traumatic brain injury (TBI) and hypovolemic shock, submitted to treatment with varying amounts of FWB, compared to similar resuscitation goals with fractionated blood products-red blood cells (RBCs) and plasma in a 1:1 ratio regimen. 40 male Lewis rats were divided into control and treatment groups. TBI was inflicted by a free-falling rod on the exposed cranium. Hypovolemia was induced by controlled hemorrhage of 30% blood volume. Treatment groups were treated either with fresh whole blood or with RBC + plasma in a 1:1 ratio, achieving a resuscitation goal of a mean arterial blood pressure (MAP) of 80mmHg at 15min. MAP was assessed at 60min, and neurological outcomes and mortality in the subsequent 24h. At 60min, hemodynamic parameters were improved compared to controls, but not significantly different between treatment groups. Survival rates at 48h were 100% for both of the mildly resuscitated groups (MABP 80mmHg) with FWB and RBC + plasma. The best neurological outcomes were found in the group mildly resuscitated with FWB and were better when compared to resuscitation with RBC + plasma to the same MABP goal (FWB: Neurological Severity Score (NSS) 6 ± 2, RBC + plasma: NSS 10 ± 2, p = 0.02). In this study, we find that mild resuscitation with goals of restoring MAP to 80mmHg (which is lower than baseline) with FWB, provided better hemodynamic stability and survival. However, the best neurological outcomes were found in the group resuscitated with FWB. Thus, we suggest that resuscitation with FWB is a feasible modality in the combined TBI + hypovolemic shock scenario, and may result in improved outcomes compared to platelet-free component blood products.

This pilot study obtained preliminary data on the effects of acupuncture treatment combined with a standard inpatient stroke rehabilitation program on poststroke motor recovery and physical function. Thirty-two patients with acute stroke were recruited and randomized to 1 of 2 treatment arms: standard rehabilitation (control group) or a combination of acupuncture and standard rehabilitation (acupuncture group). Baseline and discharge assessments were obtained on motor recovery as measured by the Fugl-Meyer (FM) Assessment and on physical function as measured by the Functional Independence Measure (FIM). Comparisons were made between the acupuncture and control group in total FM and FIM as well as for each subscale of the FM and FIM. No differences between treatment groups were found in the total FM or the total FIM. However, statistically significant benefit due to acupuncture was observed for the FM lower extremity motor function subscale (P = 0.01) and the tub/shower transfer mobility subscale of the FIM (P = 0.03). Marginally significant benefit due to acupuncture was noted for the toilet transfer mobility subscale of the FIM (P = 0.09). The effectiveness of acupuncture as an adjunct to standard poststroke rehabilitation programs may be demonstrated when more specific measures of stroke motor recovery and physical function are used.

Background Concomitant traumatic brain injury with spinal cord injury is likely to worsen prognosis and increase hospital length of stay. This study assessed the duration of in-patient rehabilitation and outcome in patients with both traumatic brain injury and spinal cord injury. Methods Retrospective study of all patients with concomitant traumatic brain injury and spinal cord injury over a 3-year period who had 5 years of subsequent follow-up at the Midlands Centre for Spinal Injuries. Results Twenty-seven patients had concomitant injuries of which five had severe traumatic brain injury, nine had moderate traumatic brain injury and the remaining thirteen had mild traumatic brain injury with spinal cord injury of grades A–D; commonest mechanisms of injury were motor vehicle collision (55%) and falls (37%). Thirteen (48%) had tetraplegia and 14 (52%) had paraplegia. Mean functional independence measure score at admission was 52.1 and 103.4 at 5 years. Patients with mild traumatic brain injury gained a mean functional independence measure score of 67.1; the moderate and severe traumatic brain injury patients gained mean functional independence measure score of 60.1 and 69.2, respectively. The mean length of stay was 138.3, 139.4 and 153.4 days for mild, moderate and severe traumatic brain injury, respectively. Conclusion Hospital length of stay and patient’s functioning at 5 years were not affected by traumatic brain injury severity in this subgroup; however, functional independence measure on its own may not be very sensitive to cognitive deficits.

Objective To investigate the effect of hyperbaric oxygen intervention time on Glasgow Coma Score (GCS) and functional independent measure (FIM) scores in patients following traumatic brain injury, so as to provide clinical evidence for optimal intervention time in the comprehensive rehabilitation of those patients. Methods There were 130 patients with moderate or severe traumatic brain injury (TBI), who were divided according to different injury time into 4 groups: the control group (n=25), the HBO group 1 (TBI 30 d) (n=25). The patients in all the groups received drug therapy and rehabilitation treatment measures. On the basis of the above routine treatment, the patients in all the HBO groups were treated with HBO for a total of 40 sessions. Therapeutic efficacy was assessed by using GCS and FIM scores performed respectively at day one, day 30 and day 60. Results Statistical significance could be noticed in all the TBI groups in GCS and FIM scores performed at day 30 and day 60(P<0.01). For HBO group 1 and group 2, statistical differences could be seen in GCS scores detected at day 60(13.36±3.06, 13.66±1.42, 11.83±3.57), as compared with those of the control group(P<0.05). For HBO group 1 and group 2, statistical differences could also be seen in FIM scores detected respectively at day 30 and day 60, as compared with those of the control group(P<0.05). Variance in the scores of GCS and FIM was: group 1 was greater than group 2, group 2 was greater than group 3 and group 3 was greater than the control group. Conclusions Different HBO intervention time seemed to have some effect on the improvement of GCS and FIM scores in patients with traumatic brain injury. On the whole, treatment results indicated that the therapeutic effects for the HBO group 1 were superior to those for the HBO group 2, and the therapeutic effects for the HBO group 2 were superior to those for the HBO group 3. Key words: Hyperbaric oxygen; Rehabilitation; Intervention time; Functional independent measure; Glasgow Coma Score

Background : The objective of this study was to describe the functional level during the first year after moderate and severe traumatic brain injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors. Methods : A cohort of 65 patients with moderate (N = 21) or severe (N = 44) TBI were examined with FIM (Functional Independence Measure) at admission and discharge from the rehabilitation clinic (on average two months after injury) and at 12 months, and with GOSE (Glasgow Outcome Scale Extended) at 12 months after injury. Possible predictors were analyzed in a regression model using FIM total score at 12 months as outcome. Results : All mean FIM scores improved significantly from injury to discharge from sub-acute rehabilitation. In the later period from discharge to 12 months after injury, the mean FIM motor score improved in severe TBI but not in moderate TBI patients. The mean FIM cognitive scores did not improve in any of the groups. At 12 months, 95% with moderate TBI had a FIM score from 109 - 126 (functionally independent) compared to 74% with severe TBI. Functional global outcome as assessed by GOSE was “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Predictors such as PTA duration (B = -0.209), GCS admission rehabilitation (B = 5.058) and LOS rehabilitation (B = 0.458) explained 47% of the FIM variance 12 months post injury. Conclusions : The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialized rehabilitation unit. Residual disability was reported in 47% of moderate TBI patients as measured by GOSE at 12 months post injury indicating the importance of post-acute rehabilitation for these patients. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at 12 months follow-up demonstrating that these factors are common predictors of early and late TBI phases. doi:10.4021/jnr20w

Background : The objective of this study was to describe the functional level during the first year after moderate and severe traumatic brain injury (TBI), and to evaluate the predictive impact of pre-injury and injury-related factors. Methods : A cohort of 65 patients with moderate (N = 21) or severe (N = 44) TBI were examined with FIM (Functional Independence Measure) at admission and discharge from the rehabilitation clinic (on average two months after injury) and at 12 months, and with GOSE (Glasgow Outcome Scale Extended) at 12 months after injury. Possible predictors were analyzed in a regression model using FIM total score at 12 months as outcome. Results : All mean FIM scores improved significantly from injury to discharge from sub-acute rehabilitation. In the later period from discharge to 12 months after injury, the mean FIM motor score improved in severe TBI but not in moderate TBI patients. The mean FIM cognitive scores did not improve in any of the groups. At 12 months, 95% with moderate TBI had a FIM score from 109 - 126 (functionally independent) compared to 74% with severe TBI. Functional global outcome as assessed by GOSE was “good recovery” in 52% with moderate TBI versus 33% in severe TBI, “moderate disability” in 33% with moderate TBI versus 31% in severe TBI, and “severe disability” in 14% with moderate TBI versus 36% in severe TBI. Predictors such as PTA duration (B = -0.209), GCS admission rehabilitation (B = 5.058) and LOS rehabilitation (B = 0.458) explained 47% of the FIM variance 12 months post injury. Conclusions : The greatest improvement after moderate and severe TBI was in the sub-acute phase during the stay in a specialized rehabilitation unit. Residual disability was reported in 47% of moderate TBI patients as measured by GOSE at 12 months post injury indicating the importance of post-acute rehabilitation for these patients. Longer stays at the rehabilitation unit, a short PTA period and a high GCS score at admission to rehabilitation were positive predictors of functional level (FIM) at 12 months follow-up demonstrating that these factors are common predictors of early and late TBI phases. J Neurol Res. 2011;1(2):48-58 doi: https://doi.org/10.4021/jnr20w

Purpose: In some hospitals, patients exhibit significant heterogeneity of function at admission and discharge. The current study aims to assess if concurrent usage of the Early Functional Assessment (EFA) and Functional Independence Measure (FIM®) is warranted and practical in rehabilitation centers with diverse patient groups and outcomes. Methods: This retrospective study examined a data set of all patients with concurrent EFA and FIM scores admitted to a single rehabilitation center (4076 scores from 1251 patients). The patients had acquired brain injury of multiple etiologies and a range of severities. Results: The EFA scale was more able to characterize the function of lower functioning patients according to the FIM while the FIM scale was more able to characterize the function of higher functioning patients according to the EFA. This was highlighted by 21% of assessments with the lowest FIM score (18) having corresponding EFA scores of 22–76 and 27% of assessments with the highest EFA score (>90) having corresponding FIM scores of 38–126. Conclusions: In rehabilitation centers with diverse patient groups and outcomes, the FIM and EFA scale could be used to characterize the heterogeneity of function in patients with acquired brain injury. The EFA/FIM scale could be used concurrently in certain patients providing a more complete view of patients throughout the rehabilitation process.Implications for RehabilitationRehabilitation scales can be administered on multiple occasions to track the progress of a patient throughout the rehabilitation process; however, a lot of popular scales (such as the FIM®) are limited containing ceiling and floor effects for higher and lower functioning patients, respectively.In rehabilitation centers with diverse patient groups and outcomes, the FIM and EFA scale could be used to characterize the heterogeneity of function in patients with acquired brain injury.Concurrent usage of the scales could be indicated for some patients and each scale could provide information that the other scale does not provide however the FIM and EFA scales should be administered solely for EFA scores >90 (FIM administered solely) and the lowest FIM scores (EFA administered solely).

To assess the relationship between the Functional Independence Measure (FIM) and the Functional Assessment Measure (FAM), and community integration and return to work in patients with severe traumatic brain injuries (TBI). A cross-sectional, prospective design was used to collect data at 6 and 24 months postdischarge. The Return to Work Scale (RTW) and Community Integration Questionnaire (CIQ) were selected to assess return to work and community functioning. Predictor variables included the motor and cognitive subscales of the FIM and the FAM. Follow-up database of an inpatient and community TBI Rehabilitation Unit. All consenting patients with TBI admitted to the unit, aged 16 or above. There were 88 patients at 6 and 79 patients at 24 month follow-up. At 6 months follow-up, the FAM and the FIM were roughly equivalent in their ability to predict RTW and CIQ scores. At 24 months, FAM motor was the only significant predictor of CIQ, and FAM cognitive scores displayed an advantage over the FIM in predicting employment status. The FAM subscales produced only modest gains in prediction of employment status and community integration at 24 months postdischarge. This may reflect ceiling effects on the functional measures, a limited range on the RTW measure, poor ecologic validity of functional disability measures in assessing handicap, or a combination of these factors.

Introduction. Traumatic optic nerve damage is a rare complication of a head injury. Symptoms of primary damage appear at the time of first diagnostic in the early period and mask TON’s signs. Understanding of visual disturbances for the patient comes in a later period, when recovery is limited due to the irreversibility of the received injuries. Difficulties of early diagnosis of optic nerve damage in case of head trauma encourage the search for new, more informative methods. The aim of the study was to analyze the functional manifestations of the optic nerve damage in case of head injuries with different localization. Materials and methods. 366 cases (732 eyes) of patients with traumatic optic neuropathy (TON) were studied according to archival data in the period from 2014 to 2019. The control group consisted of 58 practically healthy persons (116 eyes). All patients were divided into three groups: A group - patients with traumatic brain injury (TBI) was 120 persons, B group - patients with craniofacial injury (CFI) - 118 persons and C group - with combined injuries - 128 injured. The degree of optic nerve damage was assessed using visometry, pupillometry, and perimetry. Results. In case of craniocerebral injury, decrease of visual acuity with an average value of 0.92±0.06 corresponded to degrees 0 (93%) and I (7%). In the case of craniofacial trauma, according to the research, visual acuity decreased to 0.76±0.13 (by 0.24, 24% compared to the control group, p&lt;0.05). The first degree (23%) and the second degree (7%) were determined. With a combined primary head injury, visual acuity decreased to 0.42±0.21 (by 0.58, 58%, compared to the control group, p&lt;0.05). One third were patients with I, II and III degrees of visual impairment. The use of static perimetry made it possible to detect damage to the optic nerve in patients with 0 degrees of reduced visual acuity. At the same time, 88% of patients of A group (n=120) had 0A class, 23% of B group (n=118) had 0B class, and in C group (n=122) there was almost no. The relative afferent pupillary defect’s test was negative at 0A group of vision loss, but the pupil cycle speed (PSC) was reduced in all patients. This confirms damage to the optic nerve in patients with high visual acuity This study showed that patients with TBI had high visual acuity in 93% of cases, The visual acuity was around 0.5-1.0, but sensitivity in the central part of the visual field decreased by 12 times, and the pupil reaction rate decreased by 55% compared to the control group. In case of craniofacial trauma (B group), visual acuity decreased to 0.76±0.13 (by 0.24, 24% compared to the control group, p&lt;0.05). I degree (23%) and II degree (7%) decrease of visual acuity was determined. As for the sensitivity in the central part of the visual field, it was 46.59% lower than in the A group. In patients with a combined injury of the head and face, a third of the injured had visual acuity less than 0.1, which is not found in other variants of injury. Conclusions. Analysis showed that severity of optic nerve damage depends on localization of the head injury. The use of static perimetry and pupillometry is important for the early diagnosis of TON in conditions with high visual acuity when other symptoms are weak or not amenable to examination.

Instances of traumatic brain injury (TBI) in the elderly have been increasing along with the aging of popula-tions. In the present study, we examined the effect of aging on long-term multidisciplinary in-patient rehabili-tation efficacy after TBI. Sixty-three patients with physical and cognitive impairments after TBI were enrolled in this study. Patients were divided into 4 age groups (≤ 24, 25-44, 45-64, ≥ 65 years) and the clinical charac-teristics and rehabilitation efficacy of each age group were determined. Functional disability was evaluated using motor and cognitive Functional Independence Measure (FIM) scores. Rehabilitation efficacy was assessed by FIM gains during rehabilitation and compared among the groups. There were no statistically significant dif-ferences in motor and cognitive FIM gains among the age groups. However, cognitive FIM gain was limited in a subset of ≥ 65 patients, and initial cognitive measures could not predict cognitive FIM improvement. These results indicate that chronological age is insufficient to accurately predict rehabilitation efficacy in older TBI patients, and that such patients should be considered candidates for intensive rehabilitation programs based on these results. Accurate prognostication of rehabilitation efficacy with continuing data collection is important when using rehabilitation resources for older TBI patients.

Traumatic brain injury (TBI) and subsequent post-traumatic epilepsy (PTE) often impair daily activities and mental health (MH), which contribute to long-term TBI-related disability. PTE also affects driving capacity, which impacts functional independence, community participation, and satisfaction with life (SWL). However, studies evaluating the collective impact of PTE on multidimensional outcomes are lacking. Thus, we generated a model to investigate how PTE after moderate-to-severe (ms)TBI affects TBI-associated impairments, limits activities and participation, and influences SWL. Of 5108 participants with msTBI enrolled into the National Institute for Disability, Independent Living, and Rehabilitation Research TBI Model Systems between 2010 and 2018 and with seizure-event data available at year-1 post-TBI, 1214 had complete outcome data and 1003 had complete covariate data used for analysis. We constructed a conceptual framework illustrating hypothesized interrelationships between year-1 PTE, driving status, functional independence measure (FIM), depression and anxiety, as well as year-2 participation, and SWL. We performed univariate and multivariable linear and logistic regressions. A covariate-adjusted structural equation model (SEM), using the lavaan package (R), assessed the conceptual framework's suitability in establishing PTE links with outcomes 1-2 years post-injury. Multiple parameters were evaluated to assess SEM fit. Year-1 PTE was correlated with year-1 FIM motor (standardized coefficient, βstd = -0.112, p = 0.007) and showed a trend level association with year-1 FIM cognition (βstd = -0.070, p = 0.079). Individuals with year-1 PTE were less likely to drive independently at year 1 (βstd = -0.148, p < 0.001). In addition, FIM motor (βstd = 0.323, p < 0.001), FIM cognition (βstd = 0.181, p = 0.012), and anxiety (βstd = -0.135, p = 0.024) influenced driving status. FIM cognition was associated with year-1 depression (βstd = 0.386, p < 0.001) and year-1 anxiety (βstd = 0.396, p < 0.001), whereas year-1 FIM motor (βstd = 0.186, p = 0.003), depression (βstd = -0.322, p = 0.011), and driving status (βstd = 0.233, p < 0.001) directly affected year-2 objective life participation metrics. Moreover, year-1 depression (βstd = -0.382, p = 0.001) and year-2 participation (βstd = 0.160, p < 0.001) had direct effects on year-2 SWL. SWL was influenced indirectly by year-1 variables, including functional impairment, anxiety, and driving status-factors that impacted year-2 participation directly or indirectly, and consequently year-2 SWL, forming a complex relationship with year-1 PTE. A sensitivity analysis SEM showed that the number of MH disorders was associated with participation and SWL (p < 0.001), and this combined MH variable was directly related to driving status (p < 0.02). Developing PTE during year-1 after msTBI affects multiple aspects of life. PTE effects extend to motor and cognitive abilities, driving capabilities, and indirectly, to life participation and overall SWL. The implications underscore the crucial need for effective PTE management strategies during the first year post-TBI to minimize the adverse impact on factors influencing multidimensional year-2 participation and SWL outcomes. Addressing transportation barriers is warranted to enhance the well-being of those with PTE and msTBI, emphasizing a holistic approach. Further research is recommended for SEM validation studies, including testing causal inference pathways that might inform future prevention and treatment trials.