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Objective: To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups., Design: Qualitative descriptive study guided by an access to health care services conceptual framework., Setting: Five Veterans Affairs (VA) polytrauma rehabilitation centers., Participants: SMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe)., Main Outcome Measures: Barriers and facilitators accessing care., Results: The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services., Conclusions: Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability., (Published by Elsevier Inc.)

Objective: To examine heterogeneity in the temporal patterns of depression and participation over the first 2 years post traumatic brain injury (TBI)., Design: Observational prospective longitudinal study., Setting: Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone., Participants: Persons with TBI (N=2307) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years post injury., Interventions: Not applicable., Main Outcome Measure: Patient Health Questionnaire-9 (PHQ-9) and Participation Assessment With Recombined Tools-Objective (PART-O)., Results: Using latent class modeling we examined heterogeneity in the longitudinal relationship between PHQ-9 and PART-O. The identified 6 classes were most distinct in terms of (1) level of PHQ-9 score and (2) association between the year 1 PART-O score and year 2 PHQ-9 score. For most participants, PART-O at year 1 predicted PHQ-9 at year 2 more than the reverse. However, there was a subgroup of participants that demonstrated the reverse pattern, PHQ-9 predicting later PART-O, who were on average, older and in the "other" employment category., Conclusions: Results suggest that links between participation and depression are stronger for some people living with TBI than for others and that variation in the temporal sequencing of these 2 constructs is associated with demographic characteristics. These findings illustrate the value in accounting for population heterogeneity when evaluating temporal among outcome domains., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective., Design: A cost-benefit analysis of phased approaches to sleep apnea diagnosis., Setting: Six TBI Model System Inpatient Rehabilitation Centers., Participants: Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5)., Intervention: Not applicable., Main Outcome: Cost benefit., Results: At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness., Conclusions: The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA., (Published by Elsevier Inc.)

Objective: To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions., Design: Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography., Setting: Six TBI Model System Inpatient Rehabilitation Centers., Participants: Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248., Intervention: Not applicable., Main Outcome Measures: Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47)., Results: The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, -0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples., Conclusion: This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the predictive ability of depression when considering long-term employment outcomes for individuals with moderate-to-severe traumatic brain injury (TBI) after controlling for key preinjury and injury-related variables., Design: Secondary data analysis., Setting: Community follow-up after discharge from an inpatient rehabilitation center., Participants: Individuals between 18 and 60 years old with moderate-to-severe TBI enrolled in the Traumatic Brain Injury Model Systems database., Interventions: Not applicable., Main Outcome Measures: Employment status., Results: The prevalence of employment at 2 and 5 years post injury was 40.3% and 44.5%, respectively. Individuals identified as depressed at 1 year were more likely to be unemployed at 2 years post injury (odds ratio [OR], 1.77; 95% CI, 1.38-2.27; P<.0001). Similar relations between current depression and future employment were observed from 1- and 2-year depression status predicting 5-year employment (1-year: OR, 1.88; 95% CI, 1.48-2.40; P<.0001: 2-year: OR, 1.72; 95% CI, 1.36-2.17; P<.0001)., Conclusions: After controlling for baseline predictors variables, the experience of postinjury depression-a modifiable condition-contributes predictive ability to future employment outcomes. Incorporating assessments and/or interventions for depression into postacute rehabilitation programs could promote favorable employment outcomes after TBI., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the prevalence and cumulative incidence of secondary complications of spinal cord injury (SCI) in the first year after discharge from inpatient rehabilitation (IR); and to evaluate potential associations between risk of complications and sociodemographic and injury-specific factors., Design: Secondary analysis of data collected for a single-site, single-blind, randomized controlled trial comparing telephone follow-up with usual care., Setting: Inpatient rehabilitation units., Participants: Adults ages ≥18 years (N=169) within 1 year of discharge from IR after SCI., Interventions: Not applicable., Main Outcome Measures: Self-report of 10 secondary complications of SCI., Results: Participants experienced a mean of 4.7 complications over 12 months. The most frequently reported complications were urinary tract infection (UTI), autonomic dysreflexia (AD), and pressure ulcers, with cumulative incidences of 62%, 43%, and 41%, respectively. Bone and soft tissue injuries (cumulative incidence, 35%) and bowel problems, including impaction or severe constipation (cumulative incidence, 33%), were also common. Cumulative incidences of AD, decubitus ulcers, UTI, and problems with bladder were greater in participants with higher level and more complete injuries, and some recurrent complications were common. Age at injury and impairment level significantly affected rates of complications, and subjects developed an average of 2.33 distinct complications during the study period., Conclusions: People with SCI are at high risk for a number of secondary complications over the first year after discharge from IR. Although these data offer some insight into who with SCI is at highest risk for first time and recurrent complications, further study is needed to refine this understanding and to develop effective educational and prevention strategies., (Copyright © 2017 American Congress of Rehabilitation Medicine. All rights reserved.)

Objectives: To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes., Design: Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI., Setting: Inpatient rehabilitation unit., Participants: From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed., Interventions: Not applicable., Main Outcome Measure: Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI., Results: Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%-93%), a specificity of 51% (95% confidence interval, 39%-64%), and a Youden Index of 0.3 (95% confidence interval, 0.2-0.5). Compared with those without TBI, those with chart review-determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes., Conclusions: Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the role of residential neighborhood characteristics in accounting for race disparities in participation among a large sample of community-living adults with chronic spinal cord injury (SCI)., Design: Secondary analysis of cross-sectional survey data from the national Spinal Cord Injury Model Systems (SCIMS) database linked with national survey and spatial data., Setting: SCIMS database participants enrolled at 10 collaborating centers active in follow-up between 2000 and 2014., Participants: The sample consisted of persons with SCI (N=6892) in 5441 Census tracts from 50 states and the District of Columbia., Intervention: Not applicable., Main Outcome Measure: The Craig Handicap Assessment and Reporting Technique was used to measure full participation across 4 domains: physical independence, mobility, occupation, and social integration., Results: Racial minority groups had lower odds of reporting full participation relative to whites across all domains, suggesting that blacks and Hispanics are at risk for poorer community reintegration after SCI. Neighborhood characteristics, notably differences in socioeconomic advantage, reduced race group differences in the odds of full occupational and social integration, suggesting that the race disparities in community reintegration after SCI are partially attributable to variation in the economic characteristics of the places where people live., Conclusions: This investigation suggests that addressing disadvantage at the neighborhood level may modify gaps in community participation after medical rehabilitation and provides further support for the role of the environment in the experience of disability., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the outcomes and lessons learned from a trial of telephone counseling (TC) to reduce medical complications and health care utilization and to improve psychosocial outcomes during the first year after spinal cord injury rehabilitation., Design: Single-site, single-blind, randomized (1:1) controlled trial comparing usual care plus TC with usual care (UC)., Setting: Two inpatient rehabilitation programs., Participants: Adult patients (N=168) discharged between 2007 and 2010., Interventions: The TC group (n=85, 51%) received up to eleven 30- to 45-minute scheduled telephone calls to provide education, resources, and support. The UC group (n=83, 49%) received indicated referrals and treatment., Main Outcome Measures: The primary outcome was a composite of self-reported health care utilization and medical complications. Secondary outcomes were depression severity, current health state, subjective health, and community participation., Results: No significant differences were observed between TC and UC groups in the primary or secondary psychosocial outcomes., Conclusions: This study had a number of strengths, but included potential design weaknesses. Intervention studies would benefit from prescreening participants to identify those with treatable problems, those at high risk for poor outcomes, or those with intentions to change target behaviors. Interventions focused on treatment goals and designed to work in collaboration with the participant's medical care system may lead to improved outcomes., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the number and type of longitudinal depression trajectories during the first year after spinal cord injury (SCI) and to identify baseline predictors of these trajectories., Design: Cohort study., Setting: Rehabilitation and postacute community settings., Participants: Of 168 consecutive admissions to inpatient rehabilitation for acute SCI, 141 (115 men, 26 women) patients were enrolled in a randomized controlled trial telephone follow-up intervention, which showed no outcome differences, and completed assessments on at least 2 of the 4 follow-up occasions (3, 6, 9, and 12 months after SCI). Participants were on average 41 years old, most were non-Hispanic (96%) and white (86%), and 61.7% had tetraplegia., Interventions: Data were drawn from the ineffective randomized controlled trial., Main Outcome Measure: Patient Health Questionnaire-9 (PHQ-9)., Results: Unconditional linear latent class growth analysis models of PHQ-9 total scores revealed an optimal 3-class solution: stable low depression (63.8%), mild to moderate depression (29.1%), and persistent moderate to severe depression (7.1%). Preinjury mental health history and baseline pain, quality of life, and grief predicted class membership., Conclusions: The modal response to SCI was stable low depression, whereas persistent moderate to severe depression primarily represented a continuation or relapse of preinjury depression. This line of research has the potential to improve identification of subgroups destined for poor outcomes and to inform early intervention studies., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine headache trajectories among persons with mild traumatic brain injury (MTBI) in the year after injury and the relation of headache trajectory to posttraumatic stress disorder (PTSD) at 1 year postinjury., Design: Prospective, longitudinal study., Setting: Participants were recruited through a university medical center and participated in follow-up assessments by telephone., Participants: Prospectively enrolled individuals (N=212) within 1 week of MTBI who were hospitalized for observation or other system injuries. Participants were assessed at baseline and 3, 6, and 12 months postinjury., Interventions: Not applicable., Main Outcome Measures: Participants rated average headache pain intensity using the 0 to 10 numerical rating scale at each assessment period. The PTSD Checklist-Civilian Version was completed at 12 months postinjury., Results: Latent class growth analysis produced a 4-trajectory group model, with groups labeled resolved, worsening, improving, and chronic. Multivariate regression modeling revealed that younger age and premorbid headache correlated with membership in the worse trajectory groups (worsening and chronic; P<.001). Univariate regression revealed a significant association between PTSD and membership in the worse trajectory groups (P<.001)., Conclusions: Headache is common in the year after MTBI, with younger people, persons who previously had headaches, and persons with PTSD more likely to report chronic or worsening headache. Further research is needed to examine whether PTSD symptoms exacerbate headaches or whether problematic headache symptoms exacerbate PTSD., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine whether grief is a psychometrically sound construct that is distinct from depression in individuals who have recently sustained a spinal cord injury (SCI)., Design: Cross-sectional survey., Setting: Inpatient rehabilitation units at 3 geographically diverse, university-affiliated medical centers., Participants: Patients with SCI (N=206) were recruited (163 men [79.1%]). Most patients were non-Hispanic whites (n=175 [85.0%]). Most patients sustained a cervical SCI (n=134 [64.4%]). Various injury etiologies were represented, with the majority being accounted for by falls (n=72 [31.5%]) and vehicle-related accidents (n=69 [33.5%]). The mean time since injury was 53.5±40.5 days., Interventions: Not applicable., Main Outcome Measures: An adapted version of the 12-item structured clinical interview for Prolonged Grief Disorder was used to assess symptoms of grief, and the Patient Health Questionnaire-9 was used to measure depression. Demographic and injury-related data were also collected., Results: A principal component analysis (with direct oblimin rotation) of the grief measure suggested a 2-component solution. The content of items loading on the separate components suggested 2 subscales: loss (6 items; Cronbach α=.810) and trauma (6 items; Cronbach α=.823). Follow-up principal component analyses including both grief and depression measures suggested clear differentiation of grief-related loss from depression. The prevalence of clinically significant levels of grief was low (6%), and levels of depression were consistent with previous findings related to inpatient rehabilitation (23.5%)., Conclusions: The items used to assess grief symptoms in patients participating in inpatient rehabilitation for recently sustained SCI appear to capture a psychometrically reliable construct that is distinct from that of depression. Research is needed on the predictive validity of early grief symptoms after SCI and the relation of grief to other psychological constructs over time., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI)., Design: Cross-sectional survey., Setting: Community based., Participants: Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point., Interventions: None., Main Outcome Measures: Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form., Results: Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P<.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P<.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069)., Conclusions: Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI)., Design: Longitudinal survey design with 1-year follow-up., Setting: Inpatient rehabilitation and the community., Participants: Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI., Interventions: Not applicable., Main Outcome Measures: Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥ 4 were classified as having pain, and participants with PHQ-9 scores ≥ 10 were classified as depressed., Results: Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001)., Conclusions: Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether demographic, injury, health, and functional factors similarly have the same predictive relation with both somatic and nonsomatic symptoms of depression, as well as whether somatic and nonsomatic symptoms of depression have the same association with quality of life (QOL)., Design: Secondary analysis of cross-sectional survey data., Setting: Community, Participants: Patients with traumatic spinal cord injury (N=4976) who completed an interview at 1 year postinjury between 2006 and 2011., Interventions: Not applicable., Main Outcome Measures: Somatic and nonsomatic symptoms of depression from the Patient Health Questionnaire-9 and QOL measured by the Satisfaction With Life Scale., Results: Structural equation modeling showed that the hypothesized model provided a good fit to the data, but modification of the model led to a significant improvement in model fit: Δχ(2)(1)=226.21, P<.001; comparative fit index=.976; χ(2)(199)=585.39, P<.001; root mean square error of approximation=.027 (90% confidence interval, .025-.030). The health-related factors including pain severity, pain interference, and health status were similarly associated with both somatic and nonsomatic symptoms of depression. QOL was negatively associated with nonsomatic symptoms of depression but was unrelated to somatic symptoms of depression., Conclusions: Assessment of depression after spinal cord injury should include a careful assessment of health concerns given the relation between health-related factors and both somatic and nonsomatic symptoms of depression. Treatments of depressive symptoms may be improved by targeting health concerns, such as pain, along with a specific focus on nonsomatic symptoms to improve the QOL., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine patterns of change and factors associated with change in depression, both major (major depressive disorder [MDD]) and minor, between 1 and 2 years after traumatic brain injury (TBI)., Design: Observational prospective longitudinal study., Setting: Inpatient rehabilitation centers, with 1- and 2-year follow-up conducted primarily by telephone., Participants: Persons with TBI (N=1089) enrolled in the Traumatic Brain Injury Model Systems database, followed at 1 and 2 years postinjury., Interventions: Not applicable., Main Outcome Measure: Patient Health Questionnaire-9., Results: Among participants not depressed at 1 year, close to three fourths remained so at 2-year follow-up. However, 26% developed MDD or minor depression between the first and second years postinjury. Over half of participants with MDD at year 1 also reported MDD the following year, with another 22% reporting minor depression; thus three fourths of those with MDD at year 1 experienced clinically significant symptoms at year 2. Almost one third of those with minor depression at year 1 traversed to MDD at year 2. Polytomous logistic regression confirmed that worse depression at year 1 was associated with higher odds of depression a year later. For those without depression at year 1, symptom worsening over time was related to year 2 problematic substance use and lower FIM motor and cognitive scores. For those with depression at year 1, worsening was associated with lower cognitive FIM, poor social support, and preinjury mental health issues including substance abuse., Conclusions: Major and minor depression exist on a continuum along which individuals with TBI may traverse over time. Predictors of change differ according to symptom onset. Results highlight importance of long-term monitoring for depression, treating minor as well as major depression, and developing interventions for comorbid depression and substance abuse., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare individuals' sleep 1 year after traumatic brain injury (TBI) with that of a healthy comparison group, and examine the relationship between sleep, co-occurring conditions, and functional status in those with TBI., Design: Longitudinal assessment of a prospectively studied sample of individuals with moderate to severe TBI. Assessment of sleep occurred at 1 year after TBI., Setting: Inpatient acute rehabilitation for TBI and community follow-up at 1 year postinjury., Participants: Individuals with TBI (N=174) were recruited from consecutive admissions to an inpatient rehabilitation unit and enrolled into the TBI Model Systems study. Participant mean age was 38, and mean Glasgow Coma Scale score on admission was 9.3. Seventy-eight percent of the sample were men., Interventions: None., Main Outcome Measures: Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI). Depression, anxiety, and pain were measured with the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 Scale, and an analog pain rating scale, respectively., Results: Participants with TBI reported significantly greater sleep difficulties than the healthy comparison group. Forty-four percent of participants with TBI reported significant sleep problems (PSQI>5). Participants with 1 or more co-occurring conditions (depression, pain, or anxiety) had significantly worse sleep than those without such a condition. The highest level of sleep problems was reported by participants with multiple co-occurring conditions. Sleep problems were also associated with poor functional status., Conclusions: Sleep difficulties are a frequent problem at 1 year after TBI, and often co-occur with depression, anxiety, and pain. Assessment and treatment of sleep difficulties should be included in clinical practice. Future research on the potential causal relationship among co-occurring conditions may assist in additional intervention planning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on use of inpatient rehabilitation for individuals with traumatic brain injury (TBI)., Design: Retrospective cohort study of patients with TBI., Setting: One hundred twenty-three level I and II trauma centers across the U.S. who contributed data to the National Trauma Data Bank., Participants: Patients (N=135,842) with TBI and an Abbreviated Injury Score of the head of 2 or greater admitted to trauma centers between 1995 and 2004., Interventions: None., Main Outcome Measure: Discharge location: IRF, skilled nursing facility, home, and other hospitals., Results: Compared with inpatient rehabilitation admissions before IRF PPS came into effect, demographic characteristics of admitted patients changed. Those admitted to acute care trauma centers after PPS was enacted (January 2002) were older and nonwhite. No differences were found in rates of injury between men and women. Over time, there was a significant drop in the percent of patients being discharged to inpatient rehabilitation, which varied by region, but was found across all insurance types. In a logistic regression, after controlling for patient characteristics (age, sex, race), injury characteristics (cause, severity), insurance type, and facility, the odds of being discharged to an IRF after a TBI decreased 16% after Medicare's IRF PPS system was enacted., Conclusions: The enactment of the Medicare PPS appears to be associated with a reduction in the chance that patients receive inpatient rehabilitation treatment after a TBI. The impact of these changes on the cost, quality of care, and patient outcome is unknown and should be addressed in future studies., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the effect of exercise intervention on exercise maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression., Design: Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention., Setting: Community., Participants: Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9., Interventions: Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group., Main Outcome Measure: Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week., Results: Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health., Conclusions: Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the incidence of and factors associated with the development of posttraumatic stress disorder (PTSD) 6 months after civilian mild traumatic brain injury (MTBI)., Design: Secondary analysis of a randomized controlled trial of telephone follow-up versus usual care to reduce MTBI symptoms and improve function., Setting: In-person and telephone interviews., Participants: Prospectively studied participants (N=239) with MTBI enrolled in the emergency department., Interventions: Not applicable., Main Outcome Measures: Secondary analysis with main outcome measure of Posttraumatic Stress Disorder Checklist-Civilian Version., Results: At 6 months after MTBI, 17% of participants met criteria for diagnosis of PTSD. Logistic regression predicting PTSD from baseline characteristics showed that participants who were Hispanic versus white, non-Hispanic and who, at the time of injury, described themselves as less happy and believed they would be more affected by their injury were significantly more likely to have PTSD., Conclusions: Rates of PTSD in civilian MTBI in this study are consistent with prior research. Results suggest that personality characteristics and attribution regarding the injury may impact the development of PTSD. Early interventions addressing risk factors may prevent or reduce the likelihood of developing PTSD., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury., Design: Longitudinal cohort study., Setting: SCI Model System., Participants: Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009., Interventions: Not applicable., Main Outcome Measure: Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher., Results: Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found., Conclusion: In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine how persons move back and forth along levels of mobility disability., Design: Self-reported mobility limitations were used to create categories of annual transition states. The total cost to Medicare associated with each year was calculated for each participant. In addition, we examined cost relative to transition state, adjusting for demographic and other health status variables., Setting: National survey., Participants: Participants in the longitudinal Medicare Current Beneficiary Survey from 1992 to 2005., Interventions: Not applicable., Main Outcome Measures: Annual self-reported mobility limitations and total Medi costs., Results: Most participants remained without mobility limitations or improved over time. Reported average costs were 10 times higher for those who transitioned to severe limitations, unable to walk, or death compared with persons who reported no mobility limitation. Estimated costs were highest for those transitioning to increased states of disability and to death., Conclusions: Mobility limitations in older adults are dynamic, and improvement (as measured by annual transitions) occurred for a large number of Medicare beneficiaries. High total annual costs were observed in groups that transitioned to worsening mobility states, suggesting a link between mobility limitation transitions and cost. Prevention and treatment of mobility limitation may be an important factor to consider in health care reform., (Published by Elsevier Inc.)

Unlabelled: Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial., Objective: To test the hypotheses that hydrophilic catheters reduce the incidence of symptomatic urinary tract infections (UTIs) in persons with spinal cord injury on self-intermittent catheterization (IC)., Design: Randomized controlled trial., Setting: Community., Participants: Subjects (N=56) on IC with recurrent UTIs and who met eligibility criteria., Intervention: Use of hydrophilic catheters for IC., Main Outcome Measure: Symptomatic UTIs treated with antibiotics., Results: Of the 56 subjects enrolled, 45 completed the study (22 in the treatment group, 23 in the control group). There were no significant differences in demographics, including sex, between the treatment group and the controls except for more tetraplegic subjects in the control group (P<.05). Seventy-one percent of the treatment group and 52% of the control group were men. The total number of symptomatic UTIs treated with antibiotics was significantly smaller in the treatment group than in the control group (P<.05). Seventy percent of the control group had at least 1 antibiotic treatment episode compared with only 50% of those with the hydrophilic catheter (P=.18). There was no significant difference in the incidence of bacteriuria or symptomatic UTIs among the 2 groups. Level of injury and years with injury were unrelated to symptomatic UTIs, but being female increased the risk of UTIs (P<.01)., Conclusions: Although there was no difference in the number of symptomatic UTIs in the 2 groups, hydrophilic catheter usage was associated with reduced numbers of treated UTIs as compared with standard nonhydrophilic catheters in persons with spinal cord injury who used self-IC; however, the study is limited by a small sample size. Women on self-IC were more likely to develop UTIs regardless of the catheter type, suggesting that the benefits of the lubrication may be more important in men.

Objective: To examine the temporal relationship between self-reported injury-related functional limitations and depressive symptomatology after traumatic brain injury (TBI)., Design: A longitudinal cohort study with 3 evaluation points., Setting: A level I trauma center., Participants: Adolescents and adults (N=135) with complicated mild to severe TBI (72% had complicated mild injuries) who were recruited within 24 hours of injury and then completed the measure at all 3 time points., Interventions: Not applicable., Main Outcome Measures: Sickness Impact Profile and Center for Epidemiological Studies-Depression Scale., Results: Individuals who reported more depressive symptomatology consistently endorsed more injury-related difficulties, showing the strong relationship between depression and perceived psychosocial functioning. Examination of these relationships over time revealed that increased depressive symptomatology follows higher levels of perceived injury-related changes but that reports of injury-related changes are not associated with earlier depression. These findings suggest a unidirectional temporal relationship between these variables., Conclusions: Perceived changes in daily functioning appear to influence emotional well-being over time after TBI. However, depressive symptoms do not appear to negatively impact individuals' perception of later functioning. These results further our understanding of the complicated relationship between these variables and may have important implications for treatment of depression after TBI.

Objective: To describe assistance from helpers and use of assistive technology and environmental modification by community-dwelling people with difficulties in activities of daily living (ADLs) and instrumental activities of daily living (IADLs)., Design: Cross-sectional study using the 2004 Medicare Current Beneficiary Survey., Setting: Community., Participants: Nationally representative sample of 14,500 Medicare beneficiaries (mean age, 71.5 y; 55% female; 49% currently married; 68% living with others; 84% white)., Interventions: Not applicable., Main Outcome Measures: Self-reported difficulty with ADLs and IADLs; uses of help, assistive technology, and/or environmental modification., Results: Difficulties were reported most frequently for heavy housework, walking, and shopping; money management, shopping, and light housework were reported as activities most often needing a helper. Walking, bathing, and toileting were activities most often needing uses of assistive technology. Bathroom modifications were the most commonly reported environmental modification. Results from a logistic regression showed that advancing age was the primary factor associated with increasing use of helpers and assistive technology or both for difficult activities., Conclusions: Uses of helpers, assistive technology, and environmental modification are common but vary by type of ADL and/or IADL and age. Focused studies regarding uses of help and access to assistive technology and environmental modification appear needed to support community living. Public education about methods and types of accommodations appears needed and may substitute for or augment guidance from care providers.

Objective: To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators., Design: Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patient's disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y)., Setting: National survey., Participants: Participants (N=29,074) of the Medicare Current Beneficiary Survey (1992-2001) with no, increasing, decreasing, and stable ADL disability., Interventions: Not applicable., Main Outcome Measure: The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension., Results: For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits)., Conclusions: Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability status varies depending on the indicator measured. In this cohort of patients, the changing nature of a person's disability seems to have less impact than whether they ever have had any functional deficits.

Objective: To examine the association between satisfaction with health care, the use of preventive health care, and mobility limitation., Design: Cross-sectional analysis of survey data., Setting: Community., Participants: A total of 12,769 people, age greater than 65, who participated in the 2001 Medicare Current Beneficiary Survey., Interventions: Not applicable., Main Outcome Measures: Self-report of mobility limitation, satisfaction, and use of preventive health care (immunizations, cancer screening). Sampling weights were used in all analyses, including logistic regression for survey data, to calculate estimates for a Medicare population of 31 million., Results: After controlling for sociodemographic characteristics, Medicare beneficiaries with mobility limitations were significantly more dissatisfied with their health care compared with beneficiaries without mobility limitations. Receipt of preventive care did not differ for those with and without mobility limitation on some preventive services., Conclusions: Mobility limitation is highly associated with dissatisfaction with health care among older adult beneficiaries. Although Medicare beneficiaries may receive similar rates of preventive care, those with mobility limitation may have more difficulty accessing services and be more dissatisfied with their health care in general.

Understanding the use of weights in the analysis of data from multistage surveys. Large national surveys are powerful tools with which to examine a variety of important rehabilitation-related issues and are currently the only feasible method to study disability trends over time. Because it is impractical to draw simple random samples from the entire United States, national surveys, such as the Medicare Current Beneficiary Survey (MCBS), select random samples of subgroups of a population. Thus, respondents may have unequal probabilities of being included in the survey, and weighting must be used in the analysis before the results may be generalized to the entire United States. Surveys such as the MCBS are rich sources of data for rehabilitation medicine, and it can be expected that more research will be conducted using these data sources. Statistical analysis of these data should account for the sampling scheme used in data collection. We review the principles involved in the design of multistage samples, the calculation of weights, and their use in the data analysis, focusing on their importance in the estimation of population values. Our objective is to help readers to understand and interpret results of research articles using this methodology. Examples using the MCBS data are provided to clarify the concepts presented in the article.

Objective: To measure the effectiveness of a scheduled telephone intervention offering counseling and education to people with traumatic brain injury (TBI) on behavioral outcomes compared with standard follow-up at 1 year postinjury., Design: Two-group randomized, prospective clinical trial throughout the first year after injury., Setting: Subjects' homes via telephone in an urban-rural catchment area from a level I trauma center., Participants: Subjects (N=171; age range, 18-70 y) with a primary diagnosis of TBI who were discharged from an acute rehabilitation unit. They were randomly assigned to the telephone intervention (n=85) or to standard follow-up (n=86) groups at discharge. Of these, 79 participated in the intervention and completed the outcome assessment (3 withdrew; 3 were lost to follow-up), and 78 participated in usual care and completed the outcome assessment (8 were lost to follow-up)., Interventions: Subjects were randomly assigned to receive telephone calls at 2 and 4 weeks and 2, 3, 5, 7, and 9 months after discharge. The calls consisted of brief motivational interviewing, counseling, and education, plus facilitating usual care or usual care alone through follow-up appointments and therapy prescriptions., Main Outcome Measures: A composite outcome was used as the primary endpoint on an intent-to-treat basis. Secondary analyses were conducted with individual measures, including the FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Neurobehavioral Functioning Inventory, Functional Status Examination, Glasgow Outcome Scale-Extended, Medical Outcomes Study 36-Item Short-Form Health Survey, Brief Symptom Inventory, EuroQol, and Modified Perceived Quality of Life scale. The primary analysis was a blocked Mann-Whitney U test., Results: At 1-year follow-up, those who had received scheduled telephone intervention fared significantly better on the primary composite outcome index ( P =.002). In addition, this group fared better on specific composites such as functional status ( P =.003) and quality of well-being ( P =.006). There were no significant differences on vocational status ( P =.08) or community integration status ( P =.13)., Conclusions: Scheduled telephone counseling and education resulted in improved overall outcome, particularly for functional status and quality of well-being, when compared with usual outpatient care. Telephone counseling shows promise as a low-cost, widely available rehabilitation intervention for TBI.

Objective: To design and validate a methodology that identifies secondary conditions using International Classification of Disease, 9th Revision (ICD-9) codes., Design: Secondary conditions were identified through a literature search and a survey of Washington State physiatrists. These conditions were translated into ICD-9 codes and this list was then validated against a national sample of Medicare survey respondents with differing levels of mobility and activities of daily living (ADL) disability., Setting: National survey., Participants: Participants (N=9731) in the 1999 Medicare Current Beneficiary Survey with no, mild, moderate, and severe mobility and ADL disability., Interventions: Not applicable., Main Outcome Measure: Percentage of survey respondents with a secondary condition. The secondary conditions were grouped into 4 categories: medical, psychosocial, musculoskeletal, and dysphagia related (problems associated with difficulty in swallowing)., Results: Our literature search and survey of 26 physiatrists identified 64 secondary conditions, including depression, decubitus ulcers, and deconditioning. Overall, 70.4% of all survey respondents were treated for a secondary condition. We found a significant relation between increasing mobility as well as ADL disability and increasing numbers of secondary conditions (chi 2 test for trend, P <.001). This relation existed for all categories of secondary conditions: medical (chi 2 test for trend, P <.001), psychosocial (chi 2 test for trend, P <.001), musculoskeletal (chi 2 test for trend, P <.001), and dysphagia related (chi 2 test for trend, P <.001)., Conclusions: We created a valid ICD-9-based methodology that identified secondary conditions in Medicare survey respondents and discriminated between people with different degrees of disability. This methodology will be useful for health services researchers who study the frequency and impact of secondary conditions.

Objectives: To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence., Design: Survey design with analysis of cross-sectional data., Setting: Model Spinal Cord Injury Systems (MSCIS) centers., Participants: Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002., Interventions: Not applicable., Main Outcome Measures: MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups., Results: The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports., Conclusions: Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.

Objective: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation., Design: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria., Setting: Fourteen urban rehabilitation facilities throughout the United States., Participants: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807)., Interventions: Not applicable., Main Outcome Measures: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes., Results: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients., Conclusions: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.