Traumatic Brain Injury Model Systems Centers Research Articles

A Longitudinal Investigation of Alexithymia as a Predictor of Empathy, Emotional Functioning, Resilience, and Life Satisfaction Two Years after Brain Injury

To examine the unique contribution of alexithymia at 1 year after traumatic brain injury (TBI) to the prospective prediction of emotional and social health outcomes at 2 years post-injury. Multicenter, longitudinal cohort study. Data were collected during Year 1 and Year 2 post-injury follow-up interviews across four TBI Model System (TBIMS) centers. Persons with TBI (N = 175; 134 men and 41 women) who had English fluency and were capable of providing self-report data. Primary independent variable was the Toronto Alexithymia Scale-20. Outcome measures included the Interpersonal Reactivity Index, National Institute of Health Toolbox Emotion Battery Anger, Difficulty with Emotion Regulation Scale, Connor-Davidson Resilience Scale, Posttraumatic Stress Disorder Checklist-Civilian, Satisfaction With Life Scale, General Anxiety Disorder-7, Patient Health Questionnaire-9, suicidal ideation, and problematic substance use. Simple adjusted models demonstrated that after controlling for the specific outcome at Year 1, TAS-20 scores significantly predicted Year 2 scores for perspective taking, physical aggression, emotion dysregulation, resilience, anxiety, depression, and suicidal ideation. All of these predictive findings except for physical aggression were maintained in the fully adjusted models that also controlled for age, sex, education level, number of prior TBIs, and motor and cognitive functioning. Compared to those with lower alexithymia scores, persons with TBI who had higher alexithymia scores at 1-year post-injury reported poorer emotional health at 2 years after TBI, even after controlling for Year 1 outcome scores, sociodemographics, and injury-related factors. These results support the need to assess for elevated alexithymia and to provide interventions targeting alexithymia early in the TBI recovery process.

Suicide Attempts and Ideation Among Veterans/Service Members and Non-Veterans Over 5 Years Following Traumatic Brain Injury: A Combined NIDILRR and VA TBI Model Systems Study.

This study compared rates of suicide attempt (SA) and suicidal ideation (SI) during the first 5 years after traumatic brain injury (TBI) among veterans and service members (V/SMs) in the Veterans Affairs (VA) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Model Systems National Databases to each other and to non-veterans (non-Vs) in the NIDILRR database. Twenty-one NIDILRR and 5 VA TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States. Participants with TBI were discharged from rehabilitation alive, had a known military status recorded (either non-V or history of military service), and successful 1-, 2-, and/or 5-year follow-up interviews completed between 2009 and 2021. The year 1 cohort included 8737 unique participants (8347 with SA data and 3987 with SI data); the year 2 (7628 participants) and year 5 (4837 participants) cohorts both had similar demographic characteristics to the year 1 cohort. Longitudinal design with data collected across TBIMS centers at 1, 2, and 5 years post-injury. History of SA in past year and SI in past 2 weeks assessed by the Patient Health Questionnaire-9 (PHQ-9). Patient demographics, injury characteristics, and rehabilitation outcomes were also assessed. Full sample rates of SA were 1.9%, 1.5%, and 1.6%, and rates of SI were 9.6%, 10.1%, and 8.7% (respectively at years 1, 2, and 5). There were significant differences among groups based on demographic, injury-related, mental/behavioral health, and functional outcome variables. Characteristics predicting SA/SI related to mental health history, substance use, younger age, lower functional independence, and greater levels of disability. Compared with participants with TBI in the NIDILRR system, higher rates of SI among V/SMs with TBI in the VA system appear associated with risk factors observed within this group, including mental/behavioral health characteristics and overall levels of disability.

Societal Participation of People With Traumatic Brain Injury Before and During the COVID-19 Pandemic: A NIDILRR Traumatic Brain Injury Model Systems Study

ObjectiveTo examine the effect of the COVID-19 pandemic on societal participation in people with moderate-to-severe traumatic brain injury (TBI). DesignCross-sectional retrospective cohort. SettingNational TBI Model Systems centers, United States. ParticipantsTBI Model Systems enrollees (N=7003), ages 16 and older and 1-30 years postinjury, interviewed either prepandemic (PP) or during the pandemic (DP). The sample was primarily male (72.4%) and White (69.5%), with motor vehicle collisions as the most common cause of injury (55.1%). InterventionsNot applicable. Main Outcome MeasureThe 3 subscales of the Participation Assessment with Recombined Tools-Objective: Out and About (community involvement), Productivity, and Social Relations. ResultsOut and About, but not Productivity or Social Relations, scores were appreciably lower among DP participants compared to PP participants (medium effect). Demographic and clinical characteristics showed similar patterns of association with participation domains across PP and DP. When their unique contributions were examined in regression models, age, self-identified race, education level, employment status, marital status, income level, disability severity, and life satisfaction were variably predictive of participation domains, though most effects were small or medium in size. Depression and anxiety symptom severities each showed small zero-order correlations with participation domains across PP and DP but had negligible effects in regression analyses. ConclusionsConsistent with the effect of COVID-19 on participation levels in the general population, people with TBI reported less community involvement during the pandemic, potentially compounding existing postinjury challenges to societal integration. The pandemic does not appear to have altered patterns of association between demographic/clinical characteristics and participation. Assessing and addressing barriers to community involvement should be a priority for TBI treatment providers. Longitudinal studies of TBI that consider pandemic-related effects on participation and other societally linked outcomes will help to elucidate the potential longer-term effect the pandemic has on behavioral health in this population.

Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness

ABSTRACT Objective To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. Design Retrospective cohort. Setting NIDILRR and VA TBI Model Systems (TBIMS) centers. Participants 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). Main Outcome Measure Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. Results VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of “violent” injury types. Conclusions This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.

Distal and Proximal Predictors of Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme. TBI Model Systems centers. Individuals 16 years and older with a primary diagnosis of TBI. Prospective cohort study. Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities. Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization.

Marital Stability Over 10 Years Following Traumatic Brain Injury.

To examine the stability of marriage from the time of traumatic brain injury (TBI) to 10 years postinjury. Retrospective cohort. TBI Model Systems centers. In total, 1423 participants in the TBI Model Systems National Database who experienced TBI 10 years prior and were married at the time of injury. Not applicable. Remaining married to the same partner from the time of injury to 10-year follow-up. At 10 years, 66% (938) remained married to the same person. Significant associations were found with age at injury (P < .0001), sex (P = .0028), and preinjury problematic substance use (P = .0092). Marital stability over the 10-year period was higher for those who were older, were female, and had no problematic substance use history. Marital instability was greatest in the first year postinjury. Most married adults who received inpatient rehabilitation for TBI remained married to the same individual 10 years later. Those who were younger, were male, and had a history of problematic substance use were at a highest risk for relationship dissolution. Findings have implications for content, timing, and delivery of marital interventions. Substance use education and prevention appear to be important aspects of marital support.

Clinical Perspectives on Headache After Traumatic Brain Injury.

Headache after traumatic brain injury (TBI) is frequent and persistent over the first year after injury. Providers may need to focus on different symptom presentations depending on their patient's TBI severity. We evaluated headache symptoms in patients with moderate-to-severe TBI compared to patients with mild TBI and examined our data from two perspectives: (1) from providers who treat individuals after TBI and manage multiple postinjury symptoms including headache, and (2) from headache specialists who see individuals after TBI to manage headache. Prospective enrollment of individuals after TBI with telephone follow-up at 1-year postinjury. Enrollment from hospital and then community followup. Three hundred forty-six individuals with moderate-to-severe TBI were enrolled during acute inpatient rehabilitation across seven TBI Model System Centers. One hundred eighty-nine individuals with mild TBI were enrolled within 1 week of injury at a single center. None. Headache frequency, headache type, pain intensity, Headache Impact Test-6 (HIT-6), and depressive symptoms measured 1 year after injury. Headache prevalence is high in both TBI groups. TBI providers are more likely to evaluate and treat headache from individuals sustaining a mild TBI versus moderate-to-severe TBI. Patients with mild TBI are most likely to report tension-type headache followed by migraine-type headache. The migraine-type headache has higher impact (HIT-6) and greater pain intensity. Headache specialists may encounter patients with moderate-to-severe TBI who report more frequent headache and higher average pain scores compared to patients with mild TBI. The severity of TBI was unrelated to depressive symptoms 1 year after injury, but patients with headache were significantly more likely to have higher scores. TBI providers versus headache specialists should be aware of differences in patient symptom presentation to their respective clinics. Ongoing assessment of headache and depression over time is important following TBI of any severity.

The Longitudinal Effects of Comorbid Health Burden on Functional Outcomes for Adults With Moderate to Severe Traumatic Brain Injury.

To evaluate the impact of physical, mental, and total health condition burden on functional outcome and life satisfaction up to 10 years after moderate to severe traumatic brain injury (TBI). Six TBI Model Systems centers. Three hundred ninety-three participants in the TBI Model Systems National Database. Retrospective cohort study. Self-reported physical and mental health conditions at 10 years postinjury. Functional Independence Measure Motor and Cognitive subscales and the Satisfaction With Life Scale measured at 1, 2, 5, and 10 years. In 10-year longitudinal individual growth curve models adjusted for covariates and inverse probability weighted to account for selection bias, greater physical and mental health comorbidity burden was negatively associated with functional cognition and life satisfaction trajectories. Physical, but not mental, comorbidity burden was negatively associated with functional motor trajectories. Higher total health burden was associated with poorer functional motor and cognitive trajectories and lower life satisfaction. This study offers evidence that comorbidity burden negatively impacts longitudinal functional and life satisfaction outcomes after TBI. The findings suggest that better identification and treatment of comorbidities may benefit life satisfaction, functional outcome, reduce healthcare costs, and decrease reinjury. Specific guidelines are needed for the management of comorbidities in TBI populations.

Longitudinal Effects of Medical Comorbidities on Functional Outcome and Life Satisfaction After Traumatic Brain Injury: An Individual Growth Curve Analysis of NIDILRR Traumatic Brain Injury Model System Data.

To explore associations of specific physical and neuropsychiatric medical conditions to motor and cognitive functioning and life satisfaction over the first 10 years following traumatic brain injury (TBI). Telephone follow-up through 6 TBI Model System centers. In total, 404 individuals or proxies with TBI enrolled in the TBI Model System longitudinal study participating in 10-year follow-up. Individual growth curve analysis. FIM Motor and Cognitive subscales, Satisfaction With Life Scales, and Medical and Mental Health Comorbidities Interview. Hypertension, diabetes, cancers, rheumatoid arthritis, and anxiety negatively affected the trajectory of motor functioning over time. Diabetes, cancers, chronic bronchitis, anxiety, and depression negatively impacted cognitive functioning. Numerous neuropsychiatric conditions (sleep disorder, alcoholism, drug addiction, anxiety, panic attacks, posttraumatic stress disorder, depression, and bipolar disorder), as well as hypertension, liver disease, and cancers, diminished life satisfaction. Other medical conditions had a negative effect on functioning and satisfaction at specific follow-up periods. Natural recovery after TBI may include delayed onset of functional decline or early recovery, followed by progressive deterioration, and is negatively affected by medical comorbidities. Results contribute to the growing evidence that TBI is most appropriately treated as a chronic medical condition complicated by a variety of comorbid conditions.

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

ObjectiveTo develop an item response theory (IRT)-calibrated, patient-reported outcome measure of subjective independence for individuals with traumatic brain injury (TBI). DesignLarge-scale item calibration field testing; confirmatory factor analysis (CFA) and graded response model IRT analyses. SettingFive TBI Model System centers across the United States. ParticipantsAdults with complicated mild, moderate, or severe TBI (N=556). Outcome MeasuresTraumatic Brain Injury–Quality of Life (TBI-QOL) Independence item bank and the TBI-QOL Asking for Help scale. ResultsA 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. ConclusionsThe 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.

Development and Calibration of the TBI-QOL Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction With Social Roles and Activities Item Banks and Short Forms

ObjectiveTo develop traumatic brain injury (TBI)-optimized versions of the Quality of Life in Neurological Disorders (Neuro-QoL) Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks, evaluate the psychometric properties of the item banks developed for adults with TBI, develop short form and computer adaptive test (CAT) versions, and report information to facilitate research and clinical applications. DesignWe used a mixed methods design to develop and evaluate Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities items. Focus groups defined the constructs, cognitive interviews guided item revisions, and confirmatory factor analysis and item response theory methods helped calibrate item banks and evaluate differential item functioning related to demographic and injury characteristics. SettingFive TBI Model Systems centers in the United States. ParticipantsCommunity-dwelling adults with TBI (N=556). InterventionsNone. Outcome MeasuresTraumatic Brain Injury–Quality of Life (TBI-QOL) Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks. ResultsForty-five Ability to Participate in Social Roles and Activities and 41 Satisfaction with Social Roles and Activities items demonstrated good psychometric properties. Although some of the items are new, most were drawn from analogous banks in the Neuro-QoL measurement system. Consequently, the 2 TBI-QOL item banks were linked to the Neuro-QoL metric, and scores are comparable with the general population. All CAT and short forms correlated highly (>0.90) with the full item banks and demonstrate comparable construct coverage and measurement error. ConclusionThe TBI-QOL Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks are TBI-optimized versions of the Neuro-QoL Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks and demonstrate excellent measurement properties in individuals with TBI. These measures, particularly in CAT or short form format, are suitable for efficient and precise measurement of social outcomes in clinical and research applications.

Prevalence of Medical and Psychiatric Comorbidities Following Traumatic Brain Injury.

To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation. Retrospective cohort. Six TBI Model Systems (TBIMS) centers. In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior. Not applicable. Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity. At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders. People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.

Variations in Inpatient Rehabilitation Functional Outcomes Across Centers in the Traumatic Brain Injury Model Systems Study and the Influence of Demographics and Injury Severity on Patient Outcomes

ObjectiveTo compare patient functional outcomes across Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers using an enhanced statistical model and to determine factors that influence those outcomes. DesignMulticenter observational cohort study. SettingTBIMS centers. ParticipantsPatients with traumatic brain injury (TBI) admitted to 19 TBIMS rehabilitation centers from 2003–2012 (N=5505). InterventionsNot applicable. Main Outcome MeasuresFunctional outcomes of patients with TBI. ResultsIndividuals with lower functional status at the time of admission, longer duration of posttraumatic amnesia, and higher burden of medical comorbidities continued to have worse functional outcomes at discharge from inpatient rehabilitation and at the 1-year follow-up, whereas those who were employed at the time of injury had better outcomes at both time periods. Risk-adjusted patient functional outcomes for patients in most TBIMS centers were consistent with previous research. However, there were wide performance differences for a few centers even after using more recently collected data, improving on the regression models by adding predictors known to influence functional outcomes, and using bootstrapping to eliminate confounds. ConclusionsSpecific patient, injury, and clinical factors are associated with differences in functional outcomes within and across TBIMS rehabilitation centers. However, these factors did not explain all the variance in patient outcomes, suggesting a role of some other predictors that remain unknown.

TBI-QOL: Development and Calibration of Item Banks to Measure Patient Reported Outcomes Following Traumatic Brain Injury.

To use a patient-centered approach or participatory action research design combined with advanced psychometrics to develop a comprehensive patient-reported outcomes (PRO) measurement system specifically for individuals with traumatic brain injury (TBI). This TBI Quality-of-Life (TBI-QOL) measurement system expands the work of other large PRO measurement initiatives, that is, the Patient-Reported Outcomes Measurement Information System and the Neurology Quality-of-Life measurement initiative. Five TBI Model Systems centers across the United States. Adults with TBI. Classical and modern test development methodologies were used. Qualitative input was obtained from individuals with TBI, TBI clinicians, and caregivers of individuals with TBI through multiple methods, including focus groups, individual interviews, patient consultation, and cognitive debriefing interviews. Item pools were field tested in a large multisite sample (n = 675) and calibrated using item response theory methods. Twenty-two TBI-QOL item banks/scales. The TBI-QOL consists of 20 independent calibrated item banks and 2 uncalibrated scales that measure physical, emotional, cognitive, and social aspects of health-related quality of life. The TBI-QOL measurement system has potential as a common data element in TBI research and to enhance collection of health-related quality-of-life and PRO data in rehabilitation research and clinical settings.

Changes in Sexual Functioning From 6 to 12 Months Following Traumatic Brain Injury

To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI). Prospective cohort study. Community. 182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury. Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI). Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied). Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Natural History of Headache after Traumatic Brain Injury

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

Racial and Ethnic Disparities in Employment Outcomes for Persons With Traumatic Brain Injury: A Longitudinal Investigation 1-5 Years After Injury

To determine whether differences exist in employment rates between whites, blacks, and Hispanics with traumatic brain injury (TBI) at 1, 2, or 5 years after injury; to determine whether changes occur in postinjury employment rates over time for whites, blacks, and Hispanics; and to determine whether changes in postinjury employment rates over time are different for whites, blacks, and Hispanics. Sixteen TBI Model System centers. Persons (3,940) with moderate-to-severe TBI who self-reported as white, black, or Hispanic. Employment status dichotomized as competitively employed versus not competitively employed. The odds of competitive employment were significantly greater for whites versus blacks at 1, 2, and 5 years after injury and were greater for whites versus Hispanics at 1 and 2 years after injury; whites and Hispanics did not differ significantly at 5 years after injury; and blacks and Hispanics were not significantly different at 1, 2, or 5 years after injury. The odds of employment increased significantly from 1-2, 2-5, and 1-5 years after injury for whites and Hispanics, whereas the odds of employment increased from 2-5 and 1-5 years after injury for blacks, with no significant difference between 1 and 2 years after injury for blacks. No evidence was found that the changes in employment rates over time were significantly different among the race and/or ethnicity groups. Future researchers should seek to identify causative factors for employment disparities, and rehabilitation professionals should work to mitigate inequalities in employment among racial and ethnic groups with TBI.

Vocational interventions and supports following job placement for persons with traumatic brain injury

Previous research on vocational rehabilitation after traumatic brain injury (TBI) has suggested that coaching and other services provided following job placement are particularly important for successful work re-entry in this population. Methods of defining and measuring these services are needed to estimate more precisely their effects on vocational outcomes. In this study we developed a measure of the type, amount, and location of post-placement interventions that could be completed by treaters in real time. Treatment was measured prospectively for 6 months after job placement for 65 people with moderate to severe TBI treated at 5 TBI Model System centers. Centers were found to differ substantially in the amount and location of treatment provided following job placement; centers providing more intensive treatment and treatment at the workplace also served more severely impaired clients at a longer interval after injury. Within centers, participants' cognitive speed and emotional distress predicted certain aspects of amount and type of treatment provided. Three-fourths of the sample were still working at the placement job after 6 months. Due to the confounding between case mix and treatment variables, unique effects of treatments on outcomes could not be determined.

Differences in employment outcomes 10 years after traumatic brain injury among racial and ethnic minority groups

Employment outcomes of racial and ethnic minority groups with traumatic brain injury (TBI) have not been thoroughly examined in the research literature beyond five years. The objective of this study was to examine differences in employment outcomes 10 years after TBI among racial and ethnic minorities. Using a multi-center, nationwide database, 382 participants (194 minorities and 188 whites) with primarily moderate to severe TBI from 16 TBI Model System Centers were examined. A logistic regression model indicated that the odds of being competitively employed versus not competitively employed at 10 years follow-up were 2.370 times greater for whites as compared to minorities after adjusting for age at injury, pre-injury employment status, cause of injury, and total length of stay (LOS). In addition, the odds of being competitively employed at 10 years follow-up versus not being competitively employed ranged from being 1.485 to 2.553 greater for those who were younger, employed at injury, had shorter total LOS, and non-violent injuries, respectively. This study supports previous research illustrating that compared to whites, employment is less promising for minorities after TBI both short and long term. Recommendations are suggested to help rehabilitation professionals target the specific needs of minorities with TBI in order to address employment disparities through culturally-based interventions and service delivery.

Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury

Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury. Objectives To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics. Design Retrospective cohort study. Setting Sixteen TBI Model System Centers. Participants Blacks (n=615) and whites (n=1407) with moderate to severe TBI. Interventions Not applicable. Main Outcome Measure Employment status dichotomized as competitively employed versus not competitively employed. Results After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race ( P≤.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites ( P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury. Conclusions Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.