Physical Medicine and Rehabilitation Articles

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Prior history of traumatic brain injury among persons in the Traumatic Brain Injury Model Systems National Database
(Elsevier, 2013-10) Corrigan, John D.; Bogner, Jennifer; Mellick, Dave; Bushnik, Tamara; Dams-O'Connor, Kristen; Hammond, Flora M.; Hart, Tessa; Kolakowsky-Hayner, Stephanie; Physical Medicine and Rehabilitation, School of Medicine
OBJECTIVE: To determine the association between demographic, psychosocial, and injury-related characteristics and traumatic brain injury (TBI) occurring prior to a moderate or severe TBI requiring rehabilitation. DESIGN: Secondary data analysis. SETTING: TBI Model System inpatient rehabilitation facilities. PARTICIPANTS: Persons (N=4464) 1, 2, 5, 10, 15, or 20 years after TBI resulting in participation in the TBI Model System National Database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: History of TBI prior to the TBI Model System Index injury, pre-Index injury demographic and behavioral characteristics, Index injury characteristics, post-Index injury behavioral health and global outcome. RESULTS: Twenty percent of the cohort experienced TBIs preceding the TBI Model System Index injury-80% of these were mild and 40% occurred before age 16. Pre- and post-Index injury behavioral issues, especially substance abuse, were highly associated with having had a prior TBI. Greater severity of the pre-Index injury as well as occurrence before age 6 often showed stronger associations. Unexpectedly, pre-Index TBI was associated with less severe Index injuries and better functioning on admission and discharge from rehabilitation. CONCLUSIONS: Findings suggest that earlier life TBI may have important implications for rehabilitation after subsequent TBI, especially for anticipating behavioral health issues in the chronic stage of recovery. Results provide additional evidence for the potential consequences of early life TBI, even if mild.
Long-term survival after traumatic brain injury: a population-based analysis controlled for nonhead trauma
(Ovid Technologies (Wolters Kluwer) - Lippincott Williams & Wilkins, 2014-01) Brown, Allen W.; Leibson, Cynthia L.; Mandrekar, Jay; Ransom, Jeanine E.; Malec, James F.; Department of Physical Medicine and Rehabilitation, IU School of Medicine
OBJECTIVE: To examine the contribution of co-occurring nonhead injuries to hazard of death after traumatic brain injury (TBI). PARTICIPANTS: A random sample of Olmsted County, Minnesota, residents with confirmed TBI from 1987 through 1999 was identified. DESIGN: Each case was assigned an age- and sex-matched, non-TBI "regular control" from the population. For "special cases" with accompanying nonhead injuries, 2 matched "special controls" with nonhead injuries of similar severity were assigned. MEASURES: Vital status was followed from baseline (ie, injury date for cases, comparable dates for controls) through 2008. Cases were compared first with regular controls and second with regular or special controls, depending on case type. RESULTS: In total, 1257 cases were identified (including 221 special cases). For both cases versus regular controls and cases versus regular or special controls, the hazard ratio was increased from baseline to 6 months (10.82 [2.86-40.89] and 7.13 [3.10-16.39], respectively) and from baseline through study end (2.92 [1.74-4.91] and 1.48 [1.09-2.02], respectively). Among 6-month survivors, the hazard ratio was increased for cases versus regular controls (1.43 [1.06-2.15]) but not for cases versus regular or special controls (1.05 [0.80-1.38]). CONCLUSIONS: Among 6-month survivors, accounting for nonhead injuries resulted in a nonsignificant effect of TBI on long-term mortality.
Dietary intake relative to cardiovascular disease risk factors in individuals with chronic spinal cord injury: a pilot study
(Thomas Land, 2014-04-11) Lieberman, Jesse; Goff, David Jr.; Hammond, Flora; Schreiner, Pamela; Norton, H. James; Dulin, Michael; Zhou, Xia; Steffan, Lyn; Department of Physical Medicine and Rehabilitation, School of Medicine
BACKGROUND: The relationship between cardiovascular disease (CVD) risk factors and dietary intake is unknown among individuals with spinal cord injury (SCI). OBJECTIVE: To investigate the relationship between consumption of selected food groups (dairy, whole grains, fruits, vegetables, and meat) and CVD risk factors in individuals with chronic SCI. METHODS: A cross-sectional substudy of individuals with SCI to assess CVD risk factors and dietary intake in comparison with age-, gender-, and race-matched able-bodied individuals enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Dietary history, blood pressure, waist circumference (WC), fasting blood glucose, high-sensitivity C-reactive protein (hs-CRP), lipids, glucose, and insulin data were collected from 100 SCI participants who were 38 to 55 years old with SCI >1 year and compared to 100 matched control participants from the CARDIA study. RESULTS: Statistically significant differences between SCI and CARDIA participants were identified in WC (39.2 vs 36.2 in.; P < .001) and high-density lipoprotein cholesterol (HDL-C; 39.2 vs 47.5 mg/dL; P < .001). Blood pressure, total cholesterol, triglycerides, glucose, insulin, and hs-CRP were similar between SCI and CARDIA participants. No significant relation between CVD risk factors and selected food groups was seen in the SCI participants. CONCLUSION: SCI participants had adverse WC and HDL-C compared to controls. This study did not identify a relationship between consumption of selected food groups and CVD risk factors.
Dietary intake and adherence to the 2010 Dietary Guidelines for Americans among individuals with chronic spinal cord injury: a pilot study
(Maney Publishing, 2014-11) Lieberman, Jesse; Goff, David; Hammond, Flora; Schreiner, Pamela; Norton, H. James; Dulin, Michael; Zhou, Xia; Steffen, Lyn; Department of Physical Medicine and Rehabilitation, IU School of Medicine
OBJECTIVE: To investigate dietary intake and adherence to the 2010 Dietary Guidelines for Americans in individuals with chronic spinal cord injury (SCI) and able-bodied individuals. DESIGN: A pilot study of dietary intake among a sample of individuals with SCI >1 year ago from a single site compared with able-bodied individuals. PARTICIPANTS/METHODS: One hundred black or white adults aged 38-55 years old with SCI >1 year and 100 age-, sex-, and race-matched adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Dietary intake was assessed by the CARDIA dietary history. Linear regression analysis was used to compare dietary intake between the subjects with SCI and those enrolled in the CARDIA study. Further, adherence to the 2010 Dietary Guidelines for dairy, fruits, and vegetables, and whole-grain foods was assessed. RESULTS: Compared with CARDIA participants, participants with SCI consumed fewer daily servings of dairy (2.10 vs. 5.0, P < 0.001), fruit (2.01 vs. 3.64, P = 0.002), and whole grain foods (1.20 vs. 2.44 P = 0.007). For each food group, fewer participants with SCI met the recommended servings compared with the CARDIA participants. Specifically, the participants with SCI and in CARDIA who met the guidelines were, respectively: dairy, 22% vs. 54% (P < 0.001), fruits and vegetables 39% vs. 70% (P = 0.001), and whole-grain foods 8% vs. 69.6% (P = 0.001). CONCLUSIONS: Compared with able-bodied individuals, SCI participants consumed fewer daily servings of fruit, dairy, and whole grain foods than proposed by the 2010 Dietary Guideline recommendations. Nutrition education for this population may be warranted.
Exploration of a new tool for assessing emotional inferencing after traumatic brain injury
(Taylor and Francis, 2015-05) Zupan, Barbra; Neumann, Dawn; Babbage, Duncan R.; Willer, Barry; Department of Physical Medicine and Rehabilitation, IU School of Medicine
bjective: To explore validity of an assessment tool under development—the Emotional Inferencing from Stories Test (EIST). This measure is being designed to assess the ability of people with traumatic brain injury (TBI) to make inferences about the emotional state of others solely from contextual cues. Methods and procedures: Study 1: 25 stories were presented to 40 healthy young adults. From this data, two versions of the EIST (EIST-1; EIST-2) were created. Study 2: Each version was administered to a group of participants with moderate-to-severe TBI—EIST 1 group: 77 participants; EIST-2 group: 126 participants. Participants also completed a facial affect recognition (DANVA2-AF) test. Participants with facial affect recognition impairment returned 2 weeks later and were re-administered both tests. Main outcomes: Participants with TBI scored significantly lower than the healthy group mean for EIST-1, F(1,114) = 68.49, p < 0.001, and EIST-2, F(1,163) = 177.39, p < 0.001. EIST scores in the EIST-2 group were significantly lower than the EIST-1 group, t = 4.47, p < 0.001. DANVA2-AF scores significantly correlated with EIST scores, EIST-1: r = 0.50, p < 0.001; EIST-2: r = 0.31, p < 0.001. Test–re-test reliability scores for the EIST were adequate. Conclusions: Both versions of the EIST were found to be sensitive to deficits in emotional inferencing. After further development, the EIST may provide clinicians valuable information for intervention planning.
Neurobiological mechanisms associated with facial affect recognition deficits after traumatic brain injury
(Springer, 2015-06) Neumann, Dawn; McDonald, Brenna C.; West, John; Keiski, Michelle A.; Wang, Yang; Department of Physical Medicine and Rehabilitation, IU School of Medicine
The neurobiological mechanisms that underlie facial affect recognition deficits after traumatic brain injury (TBI) have not yet been identified. Using functional magnetic resonance imaging (fMRI), study aims were to 1) determine if there are differences in brain activation during facial affect processing in people with TBI who have facial affect recognition impairments (TBI-I) relative to people with TBI and healthy controls who do not have facial affect recognition impairments (TBI-N and HC, respectively); and 2) identify relationships between neural activity and facial affect recognition performance. A facial affect recognition screening task performed outside the scanner was used to determine group classification; TBI patients who performed greater than one standard deviation below normal performance scores were classified as TBI-I, while TBI patients with normal scores were classified as TBI-N. An fMRI facial recognition paradigm was then performed within the 3T environment. Results from 35 participants are reported (TBI-I = 11, TBI-N = 12, and HC = 12). For the fMRI task, TBI-I and TBI-N groups scored significantly lower than the HC group. Blood oxygenation level-dependent (BOLD) signals for facial affect recognition compared to a baseline condition of viewing a scrambled face, revealed lower neural activation in the right fusiform gyrus (FG) in the TBI-I group than the HC group. Right fusiform gyrus activity correlated with accuracy on the facial affect recognition tasks (both within and outside the scanner). Decreased FG activity suggests facial affect recognition deficits after TBI may be the result of impaired holistic face processing. Future directions and clinical implications are discussed.
Amantadine effect on perceptions of irritability after traumatic brain injury: results of the amantadine irritability multisite study
(Mary Ann Liebert, Inc., 2015-08-15) Hammond, Flora M.; Sherer, Mark; Malec, James F.; Zafonte, Ross D.; Whitney, Marybeth; Bell, Kathleen; Dikmen, Sureyya; Bogner, Jennifer; Mysiw, Jerry; Pershad, Rashmi; Physical Medicine and Rehabilitation, School of Medicine
This study examines the effect of amantadine on irritability in persons in the post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6 months post-TBI with irritability who were enrolled in a parallel-group, randomized, double-blind, placebo-controlled trial receiving either amantadine 100 mg twice daily or equivalent placebo for 60 days. Subjects were assessed at baseline and days 28 (primary end-point) and 60 of treatment using observer-rated and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item (primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between the two groups were not statistically significantly different at day 28 or 60; however, observers rated the majority in both groups as having improved at both intervals. Participant ratings for day 60 demonstrated improvements in both groups with greater improvement in the amantadine group on NPI-I Most Problematic (p<0.04) and NPI-I Distress (p<0.04). These results were not significant with correction for multiple comparisons. CGI demonstrated greater improvement for amantadine than the placebo group (p<0.04). Adverse event occurrence did not differ between the two groups. While observers in both groups reported large improvements, significant group differences were not found for the primary outcome (observer ratings) at either day 28 or 60. This large placebo or nonspecific effect may have masked detection of a treatment effect. The result of this study of amantadine 100 mg every morning and noon to reduce irritability was not positive from the observer perspective, although there are indications of improvement at day 60 from the perspective of persons with TBI and clinicians that may warrant further investigation.
Mortality following Traumatic Brain Injury among Individuals Unable to Follow Commands at the Time of Rehabilitation Admission: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study
(Liebert, 2015-12) Greenwald, Brian D.; Hammond, Flora M.; Harrison-Felix, Cynthia; Nakase-Richardson, Risa; Howe, Laura L. S.; Kreider, Scott; Department of Physical Medicine and Rehabilitation, IU School of Medicine
Severe traumatic brain injury (TBI) has been associated with increased mortality. This study characterizes long-term mortality, life expectancy, causes of death, and risk factors for death among patients admitted within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS) who lack command following at the time of admission for inpatient TBI rehabilitation. Of the 8084 persons enrolled from 1988 and 2009, 387 from 20 centers met study criteria. Individuals with moderate to severe TBI who received inpatient rehabilitation were 2.2 times more likely to die than individuals in the U.S. general population of similar age, gender, and race, with an average life expectancy (LE) reduction of 6.6 years. The subset of individuals who were unable to follow commands on admission to rehabilitation was 6.9 times more likely to die, with an average LE reduction of 12.2 years. Relative to the U.S. general population matched for age, gender, and race/ethnicity, these non–command following individuals were more than four times more likely to die of circulatory conditions, 44 times more likely to die of pneumonia, and 38 times more likely to die of aspiration pneumonia. The subset of individuals with TBI who are unable to follow commands upon admission to inpatient rehabilitation are at a significantly increased risk of death when compared with the U.S. general population and compared with all individuals with moderate to severe TBI receiving inpatient rehabilitation. Respiratory causes of death predominate, compared with the general population.
Preliminary Evaluation of a Measure for Reliable Assessment of Need for Constant Visual Observation in Adults with Traumatic Brain Injury
(Taylor & Francis, 2016) Moessner, Anne; Malec, James F.; Beveridge, Scott; Reddy, Cara Camiolo; Huffman, Tracy; Marton, Julia; Department of Physical Medicine and Rehabilitation, IU School of Medicine
Primary objective: To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation. Research design: Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity. Methods and procedures: One hundred and thirty-four individuals with moderate–severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2–3, Days 5–6 and Days 8–9. Outcomes and results: After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85–0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29–56%). Conclusions: The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.
Prevalence of suicidal behaviour following traumatic brain injury: Longitudinal follow-up data from the NIDRR Traumatic Brain Injury Model Systems
(Taylor & Francis, 2016) Fisher, Lauren B.; Pedrelli, Paola; Iverson, Grant L.; Bergquist, Thomas F.; Bombardier, Charles H.; Hammond, Flora M.; Hart, Tessa; Ketchum, Jessica M.; Giacino, Joseph; Zafonte, Ross; Department of Physical Medicine and Rehabilitation, IU School of Medicine
Objective: This study utilized the Traumatic Brain Injury Model Systems (TBIMS) National Database to examine the prevalence of depression and suicidal behaviour in a large cohort of patients who sustained moderate-to-severe TBI. Method: Participants presented to a TBIMS acute care hospital within 72 hours of injury and received acute care and comprehensive rehabilitation in a TBIMS designated brain injury inpatient rehabilitation programme. Depression and suicidal ideation were measured with the Patient Health Questionnaire (PHQ-9). Self-reported suicide attempts during the past year were recorded at each follow-up examination, at 1, 2, 3, 10, 15 and 20 years post-injury. Results: Throughout the 20 years of follow-up, rates of depression ranged from 24.8–28.1%, suicidal ideation ranged from 7.0–10.1% and suicide attempts (past year) ranged from 0.8–1.7%. Participants who endorsed depression and/or suicidal behaviour at year 1 demonstrated consistently elevated rates of depression and suicidal behaviour 5 years after TBI. Conclusion: Compared to the general population, individuals with TBI are at greater risk for depression and suicidal behaviour many years after TBI. The significant psychiatric symptoms evidenced by individuals with TBI highlight the need for routine screening and mental health treatment in this population.

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