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Importance: Chronic pain after traumatic brain injury (TBI) is prevalent and associated with poor outcomes. By providing multidisciplinary care through expert consultation, a collaborative care (CC) treatment approach may reduce pain interference., Objective: To compare CC with usual care (UC) in decreasing pain interference., Design, Setting, and Participants: This randomized clinical trial was conducted from July 2018 through April 2021 at 2 hospital-based academic rehabilitation medicine clinics in Seattle, Washington. Participants included adults with mild-to-severe TBI (at least 6 months before enrollment) and chronic pain. Data analysis was performed from March 30, 2022, to August 30, 2023., Intervention: The CC intervention (called TBI Care) included up to 12 in-person or telephone visits over 16 weeks with a care manager (CM) who provided person-centered cognitive behavioral treatment. The CM met weekly with members of the expert team to review participants and discuss recommendations to optimize treatment., Main Outcomes and Measures: The primary outcome was pain interference on the Brief Pain Inventory at treatment conclusion (4 months after randomization). Secondary outcomes included pain interference at 8 months; pain severity; symptoms of depression, anxiety, and sleep disturbance; pain-related emergency department visits; community participation; and participant satisfaction. Linear mixed-effects regression was used for analysis., Results: A total of 1379 individuals were screened for eligibility, and 158 were randomized (79 to CC and 79 to UC). The participants were mostly women (92 participants [58%]) with a mean (SD) age of 46.8 (13.2) years and a mean (SD) of 15.3 (3.0) years of education. TBI occurred a mean (SD) of 4.0 (5.9) years (median [IQR], 1.9 [0.8-4.5] years) before enrollment. All TBI severities were included, and of 149 participants for whom TBI severity was known, the majority (97 participants [65%]) had mild TBI. In the CC group, 71 participants (90%) completed at least 11 sessions, and, at 4 months, this group had significantly lower pain interference scores compared with the UC group (mean [SD], 3.46 [2.17] vs 5.03 [2.28]). This difference was maintained at 8 months after randomization, with mean (SD) TBI care pain interference scores of 3.61 (2.22) for CC vs 4.68 (2.51) for UC. At 4 months, there was significantly lower pain severity in the CC group vs UC group (mean [SD] score, 3.63 [1.95] vs 4.90 [1.96]), as well as symptoms of depression (mean [SD] score, 8.07 [5.34] vs 11.31 [6.37]) and anxiety (mean [SD], 6.20 [5.17] vs 9.58 [6.00]). Satisfaction with pain treatment (mean [SD] score, 2.99 [1.23] vs 2.52 [1.25]), clinical care (mean [SD] score, 3.28 [1.00] vs 2.84 [1.26]), and overall health care (mean [SD] score, 3.25 [0.88] vs 2.82 [1.00]) were significantly higher in the CC group vs the UC group; global impression of change was significantly lower in the CC group vs the UC group (mean [SD] score, 2.74 [1.02] vs 3.47 [1.26]) (lower scores denote a better impression of change)., Conclusions and Relevance: In this randomized clinical trial of CC compared with UC for patients with TBI, CC was effective at reducing pain interference and was sustained at 8-month follow-up. Further research is needed to examine the implementation and cost-effectiveness of CC for TBI in other health care settings., Trial Registration: ClinicalTrials.gov Identifier: NCT03523923.

We examined whether females with a history of traumatic brain injury (TBI) and intimate partner violence (IPV) have greater exposure to lifetime trauma relative to females with TBI but no IPV history. Further, we assessed the effects of lifetime trauma on psychological outcomes after TBI. Female participants ( n  = 70; age M [standard deviation-SD] = 50.5 [15.2] years) with TBI (time since injury median [interquartile range -IQR] = 10.2 [5.3-17.8] years) completed a structured assessment of lifetime history of TBI, including an IPV module to query head injuries from physical violence by an intimate partner. We characterized lifetime trauma exposure with the Adverse Childhood Experiences (ACEs) questionnaire and Survey of Exposure to Community Violence (CV). We evaluated psychological functioning with self-report questionnaires of post-traumatic stress disorder (PTSD), depression, and anxiety symptoms. Compared with those with no IPV history ( n  = 51), participants reporting IPV-related head injuries ( n  = 19; 27.1%) reported more ACEs (M[SD] IPV: 4.5[2.9]; No IPV: 1.6[1.8], p  < 0.001, d  = 1.08) and greater CV (IPV: 17.5[8.4]; No IPV: 7.6[6.1], p  < .0001, d  = 1.26). Within the full sample, ACEs (β = 0.21, 95% confidence interval [CI] = 0.04-0.39) and CV (β = 0.07, 95% CI = 0.01-0.13) predicted worse PTSD symptoms, while IPV alone did not. Exposure to all three sources of trauma (ACEs, CV, and IPV) was associated with worse PTSD symptoms relative to fewer traumas. The results highlight the scope of traumatic exposures among TBI survivors and the importance of considering IPV and other lifetime trauma exposure in assessing and managing TBI. Trauma-informed interventions that are modified for TBI-related impairment may offer improved outcomes in managing psychological symptoms.

Objective: The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI)., Setting: Community., Participants: Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach., Design: Participatory-based research design, using descriptive and intervention mapping approaches., Results: Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change., Conclusion: Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain., Setting: Community., Participants: A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up., Design: A multisite, cross-sectional observational cohort study., Main Outcome Measures: Functional outcomes, pain experience, and treatment., Results: 46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size., Conclusions: Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population., Setting: Community., Participants: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021., Design: Descriptive, qualitative study., Main Measures: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective., Results: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified., Conclusion: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no conflicts of interest.

Objective: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported., Setting: Community., Participants: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021., Design: Descriptive, qualitative study., Main Measures: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective., Results: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types., Conclusion: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the relationship between extreme pain phenotypes (interference and improvement) and psychosocial outcomes among those with chronic pain after traumatic brain injury (TBI)., Setting: Community., Participants: In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain., Design: Multisite, cross-sectional, observational cohort study., Primary Measures: Life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation, the Brief Pain Inventory (BPI) interference scale, and the Patient's Global Impression of Change (PGIC)., Results: Persons in the extreme high interference phenotype (vs extreme low interference phenotype) and/or extreme no change phenotype (vs extreme improvement phenotype) had poorer psychosocial outcomes, with extreme pain interference phenotypes having a larger effect on outcomes than extreme perceived improvement phenotypes. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptoms (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality., Conclusions: Examination of extreme phenotypes provides important insights into the experience of individuals living with chronic pain and TBI. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes., Setting: Community., Participants: Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up., Design: Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations., Main Outcome Measures: Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years)., Results: The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI., Conclusions: Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain., Setting: Community., Participants: Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury., Design: Multisite, cross-sectional observational cohort study., Main Outcome Measures: Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation)., Results: Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06)., Conclusions: Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To define and characterize extreme phenotypes based on perceived improvement in pain for persons with chronic pain following traumatic brain injury (TBI)., Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers., Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview., Primary Measures: The Patient's Global Impression of Change (PGIC) related to pain treatment. Sociodemographic, injury, functional outcome, pain, and pain treatment characteristics., Results: Participants were mostly male (73%), White (75%), middle-aged (mean 46 years), injured in motor vehicle accidents (53%), or falls (20%). Extreme phenotypes were created for an extreme improvement phenotype ( n = 512, 29.8%) defined as "moderately better" or above on the PGIC and an extreme no-change group ( n = 290, 16.9%) defined as no change or worse. Least absolute shrinkage and selection operator (LASSO) regression combined with logistic regression identified multivariable predictors of improvement versus no-change extreme phenotypes. Higher odds of extreme improvement phenotype were significantly associated with being female (odds ratio [OR] = 1.85), married versus single (OR = 2.02), better motor function (OR = 1.03), lower pain intensity (OR = 0.78), and less frequent pain, especially chest pain (OR = 0.36). Several pain treatments were associated with higher odds of being in the extreme improvement versus no-change phenotypes including pain medication (OR = 1.85), physical therapy (OR = 1.51), yoga (OR = 1.61), home exercise program (OR = 1.07), and massage (OR = 1.69)., Conclusion: Investigation of extreme phenotypes based on perceived improvement with pain treatment highlights the ability to identify characteristics of individuals based on pain treatment responsiveness. A better understanding of the biopsychosocial characteristics of those who respond and do not respond to pain treatments received may help inform better surveillance, monitoring, and treatment. With further research, the identification of risk factors (such as pain intensity and frequency) for treatment response/nonresponse may provide indicators to prompt changes in care for individuals with chronic pain after TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To define and characterize extreme phenotypes based on pain interference for persons with chronic pain following traumatic brain injury (TBI)., Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers., Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview., Primary Measures: The Brief Pain Inventory (BPI) interference scale, sociodemographic, injury, functional outcome, pain, and treatment characteristics., Results: Participants were predominantly male (73%), White (75%), middle-aged (mean 46 years), and who were injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25th percentiles to create low-interference ( n = 441) and high-interference ( n = 431) extreme phenotypes. Bivariate comparisons found several sociodemographic, injury, function, pain, and treatment differences between extreme phenotype groups, including significant differences ( P < .001) on all measures of concurrent function with those in the low-interference extreme phenotype experiencing better function than those in the high-interference extreme phenotype. Lasso regression combined with logistic regression identified multivariable predictors of low- versus high-interference extreme phenotypes. Reductions in the odds of low- versus high-interference phenotypes were significantly associated with higher pain intensity (odds ratio [OR] = 0.33), having neuropathic pain (OR = 0.40), migraine headache (OR = 0.41), leg/feet pain (OR = 0.34), or hip pain (OR = 0.46), and more pain catastrophizing (OR = 0.81)., Conclusion: Results suggest that for those who experience current chronic pain, there is high variability in the experience and impact of pain. Future research is needed to better understand how pain experience impacts individuals with chronic pain and TBI given that pain characteristics were the primary distinguishing factors between phenotypes. The use of extreme phenotypes for pain interference may be useful to better stratify samples to determine efficacy of pain treatment for individuals with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract Intimate partner violence (IPV) is associated with risk for multi-etiology brain injury (BI), including repetitive head impacts, isolated traumatic brain injuries (TBI), and anoxic/hypoxic injury secondary to nonfatal strangulation (NFS). IPV-related injuries are often unreported, but evidence suggests that survivors are more likely to report when asked directly. There are currently no validated tools for screening of brain injury related to IPV that meet World Health Organization guidelines for this population. Here, we describe measure development methods and preliminary utility of the Brain Injury Screening Questionnaire IPV (BISQ-IPV) module. We culled items from existing IPV and TBI screening tools and sought two rounds of stakeholder feedback regarding content coverage, terminology, and safety of administration. The resulting stakeholder-informed BISQ-IPV module is a seven-item self-report measure that uses contextual cues (e.g., being shoved, shaken, strangled) to query lifetime history of IPV-related head/neck injury. We introduced the BISQ-IPV module into the Late Effects of TBI (LETBI) study to investigate rates of violent and IPV-specific head/neck injury reporting in a TBI sample. Among those who completed the BISQ-IPV module ( n  = 142), 8% of the sample (and 20% of women) reported IPV-related TBI, and 15% of the sample (34% of women) reported IPV-related head or neck injury events that did not result in loss or alteration of consciousness. No men reported NFS; one woman reported inferred BI secondary to NFS, and 6% of women reported NFS events. Those who endorsed IPV-BI were all women, many were highly educated, and many reported low incomes. We then compared reporting of violent TBIs and head/neck injury events among individuals who completed the core BISQ wherein IPV is not specifically queried (administered from 2015-2018; n  = 156) to that of individuals who completed the core BISQ preceded by the BISQ-IPV module (BISQ+IPV, administered from 2019-2021; n  = 142). We found that 9% of those who completed the core BISQ reported violent TBI (e.g., abuse, assault), whereas 19% of those who completed the BISQ+IPV immediately preceding the core BISQ reported non-IPV-related violent TBI on the core BISQ. These findings suggest that standard TBI screening tools are inadequate for identifying IPV-BI and structured cueing of IPV-related contexts yields greater reporting of both IPV- and non-IPV-related violent BI. When not queried directly, IPV-BI remains a hidden variable in TBI research studies.

Traumatic brain injury (TBI) is a global health priority, associated with substantial burden. Historically conceptualised as an injury event with finite recovery, TBI is now recognised as a chronic condition that can affect multiple domains of health and function, some of which might deteriorate over time. Many people who have had a TBI remain moderately to severely disabled at 5 years, are rehospitalised up to 10 years post-injury, and have a reduced lifespan relative to the general population. Understanding TBI as a chronic disease process can be highly informative for optimising care, which has traditionally focused on acute care. Chronic brain injury care models must be informed by a holistic understanding of long-term outcomes and the factors that can affect how care needs evolve over time. The United States Traumatic Brain Injury Model Systems of Care follows up individuals with moderate-to-severe TBI for over 30 years, allowing characterisation of the chronic (2-30 years or more post injury) functional, cognitive, behavioural, and social sequelae experienced by individuals who have had a moderate-to-severe TBI and the implications for their health and quality of life. Older age, social determinants of health, and lower acute functional status are associated with post-recovery deterioration, while younger age and greater functional independence are associated with risky health behaviours, including substance misuse and re-injury. Systematically collected data on long-term outcomes across multiple domains of health and function are needed worldwide to inform the development of models for chronic disease management, including the proactive surveillance of commonly experienced health and functional challenges., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Pain after traumatic brain injury (TBI) is common and can become chronic. Acupuncture is an increasingly popular non-pharmacologic option in the United States and is commonly used for pain., Objective: We explored demographics, injury characteristics, and pain characteristics of individuals who reported using acupuncture for chronic pain after TBI., Methods: We analyzed a subset of data collected as part of the Pain After Traumatic Brain Injury collaborative study and identified individuals reporting a history of acupuncture as part of management for chronic pain after TBI. We characterized and compared basic demographic data, pain treatment engagements, pain severity, pain interference, functional independence, and pain locations using descriptive and inferential statistics., Results: Our sample included 1,064 individuals. Acupuncture use ( n  = 208) was lower proportionally among females, Blacks/African Americans, Asians, less educated, and nonmilitary service members. Insurance type varied between acupuncture and non-acupuncture users. Functional and pain outcomes were similar, but acupuncture users reported a higher number of pain sites., Discussion: Acupuncture is one treatment utilized by individuals with TBI and chronic pain. Further investigation would be helpful to understand the barriers and facilitators of acupuncture use to inform clinical trials to examine the potential benefit of acupuncture on pain outcomes after TBI.

Objective: 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., Setting: TBI Model Systems centers., Participants: Individuals 16 years and older with a primary diagnosis of TBI., Design: Prospective cohort study., Main Measures: 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., Results: 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., Conclusion: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Background: People of color (POC), especially those who also hold social identities associated with disadvantage (non-English-speaking, female, older, lower socioeconomic level), continue to be underserved in the health system, which can result in poorer care and worsened health outcomes. Most disparity research in traumatic brain injury (TBI) focuses on the impact of single factors, which misses the compounding effect of belonging to multiple historically marginalized groups., Objective: To examine the intersectional impact of multiple social identities vulnerable to systemic disadvantage following TBI on mortality, opioid usage during acute hospitalization, and discharge location., Methods: Retrospective observational design utilizing electronic health records merged with local trauma registry data. Patient groups were defined by race and ethnicity (POC or non-Hispanic White), age, sex, type of insurance, and primary language (English-speaking vs non-English-speaking). Latent class analysis (LCA) was performed to identify clusters of systemic disadvantage. Outcome measures were then assessed across latent classes and tested for differences., Results: Over an 8-year period, 10 809 admissions with TBI occurred (37% POC). LCA identified a 4-class model. Groups with more systemic disadvantage had higher rates of mortality. Classes with older populations had lower rates of opioid administration and were less likely to discharge to inpatient rehabilitation following acute care. Sensitivity analyses examining additional indicators of TBI severity demonstrated that the younger group with more systemic disadvantage had more severe TBI. Controlling for more indicators of TBI severity changed statistical significance in mortality for younger groups., Conclusion: Results demonstrate significant health inequities in the mortality and access to inpatient rehabilitation following TBI along with higher rates of severe injury in younger patients with more social disadvantages. While many inequities may be related to systemic racism, our findings suggested an additive, deleterious effect for patients who belonged to multiple historically disadvantaged groups. Further research is needed to understand the role of systemic disadvantage for individuals with TBI within the healthcare system., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objectives: To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI)., Methods: Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices., Results: Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour)., Conclusions: Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes., Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901., Citation: Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med . 2023;19(1):135-143., (© 2023 American Academy of Sleep Medicine.)

Objective: To examine the utility of the sleep disturbance item of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for insomnia among individuals with moderate to severe traumatic brain injury (TBI)., Setting: Telephone interview., Participants: A sample of 248 individuals with a history of moderate to severe TBI participated in an interview within 2 years of their injury., Design: Observational, cross-sectional analysis., Main Measures: The PHQ-9 was administered along with the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Sleep Hygiene Index, Epworth Sleepiness Scale, and the Insomnia Interview Schedule., Results: Receiver operating characteristic curve analysis was conducted for the PHQ-9 sleep item rating against a set of insomnia criteria to determine an optimal cutoff score. A cutoff of 2 on the PHQ-9 sleep item maximized sensitivity (76%) and specificity (79%), with an area under the curve of 0.79 (95% CI, 0.70-0.88). The 2 groups formed using this cutoff differed significantly on all sleep measures except the Epworth Sleepiness Scale., Conclusions: The PHQ-9 sleep item may serve as a useful screener to allow for detection of potential sleep disturbance among individuals with moderate to severe TBI. Those who screen positive using this item included in a commonly used measure of depression can be prioritized for further and more comprehensive assessment of sleep disorders., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often co-occurs with psychological and medical conditions such as posttraumatic stress disorder (PTSD) and sleep apnea. We aimed to examine if sleep apnea is associated with the presence and severity of PTSD in V/SM with TBI of all severities., Research Method: The study examined participants at varying times since their TBI ( N = 602) enrolled in the Veterans Affairs TBI Model Systems database. Frequency of self-reported sleep apnea diagnosis was calculated in a cross-sectional sample. Prevalence of co-occurring sleep apnea and probable PTSD was tested with a chi-square analysis. A multivariable regression model evaluated the association between sleep apnea and PTSD symptom severity while controlling for relevant covariates., Results: Almost 32% of the sample stated they had been diagnosed with sleep apnea. In those reporting sleep apnea, 32% also had probable PTSD; 19% of those without sleep apnea had probable PTSD. The regression demonstrated sleep apnea was significantly associated with PTSD symptom severity ( p < .001). Greater number of TBIs, recent mental health treatment, being deployed to a combat zone, and greater years since TBI were also significant predictors of PTSD symptom severity (all p < .05)., Conclusions: TBI, PTSD, and sleep apnea are often comorbid in V/SM. We expand the literature by demonstrating that sleep apnea was associated with PTSD severity. A multipronged approach to TBI rehabilitation that addresses sleep and psychological distress is recommended for enhancing health outcomes in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objectives: To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications., Setting: Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI)., Participants: A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites., Design: Cross-sectional, secondary analyses., Main Measures: The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index., Results: After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids., Conclusion: Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Due to challenges that include inconsistent access to follow-up care, persons with TBI being discharged from inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor reintegration into the community, family stress, and other unfavorable outcomes resulting from unmet needs. In a six-center randomized pragmatic comparative effectiveness study, the BRITE trial (Brain Injury Rehabilitation: Improving the Transition Experience, ClinicalTrials.govNCT03422276), we compare the effectiveness of two existing methods for transition from IRF to community living or long-term nursing care. The Rehabilitation Discharge Plan (RDP) includes patient/family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference, for 6 months. Nine hundred patients will be randomized (1:1) to RDP or RTP, with caregivers also invited to participate and contribute caregiver-reported outcomes. Extensive stakeholder input, including active participation of persons with TBI and their families, has informed all aspects of trial design and implementation planning. We hypothesize that RTP will result in better patient- and caregiver-reported outcomes (societal participation, quality of life, caregiver well-being) and more efficient use of healthcare resources at 6-months (primary outcome) and 12-months post-discharge, compared to RDP alone. Planned analyses will explore which participants benefit most from each transition model. With few exclusion criteria and other pragmatic features, the findings of this trial are expected to have a broad impact on improving transitions from inpatient TBI rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03422276., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective : To examine the impact of bright white light (BWL) exposure on sleep quality in persons with recent traumatic brain injury (TBI). Design : Randomized, controlled device-sham study Setting : 3 TBI Model System inpatient rehabilitation units Participants : 131 participants (mean 40.9 years, 68% male) Intervention : Intervention group (N = 65) received BWL (1260 lux at 20 inches, 440-480 nanometers length) for 30 minutes each morning at 12-24 inches from the face. Control group (N = 66) received red light (<450 lux, no light between 440 and 480 nanometers) for the same period. Planned intervention was maximum of 10 treatments or until discharge. Main Outcome Measure : Sleep duration and quality using actigraphic recording. Results : There were no differences found between groups on the primary outcomes nor on the secondary outcomes (sleepiness, mood, cooperation with therapy). Conclusion : BWL treatment during acute rehabilitation hospitalization does not appear to impact sleep or measures commonly associated with sleep. While studies have indicated common complaints of sleep difficulties after TBI, we were unable to document an effect for phototherapy as a treatment. With growing evidence of the effect of sleep on neural repair and cognition, further study is needed to understand the nature and treatment of sleep disorders after TBI.Clinicaltrials.gov Identifier: NCT02214212.

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.)

Background: Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations., Methods: We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated., Results: Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79., Conclusion: The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries., Level of Evidence: Epidemiologic/Therapeutic study, level IV.

Background: 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., Objective: 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., Design: Prospective enrollment of individuals after TBI with telephone follow-up at 1-year postinjury., Setting: Enrollment from hospital and then community followup., Participants: 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., Intervention: None., Main Outcome Measurements: Headache frequency, headache type, pain intensity, Headache Impact Test-6 (HIT-6), and depressive symptoms measured 1 year after injury., Results: 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., Conclusions: 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., (© 2020 American Academy of Physical Medicine and Rehabilitation.)

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.)

Objective: To build decision tree prediction models for long-term employment outcomes of individuals after moderate to severe closed traumatic brain injury (TBI) and assess model accuracy in an independent sample., Setting: TBI Model Systems Centers., Participants: TBI Model Systems National Database participants injured between January 1997 and January 2017 with moderate to severe closed TBI. Sample sizes were 7867 (year 1 postinjury), 6783 (year 2 postinjury), and 4927 (year 5 postinjury)., Design: Cross-sectional analyses using flexible classification tree methodology and validation using an independent subset of TBI Model Systems National Database participants., Main Measures: Competitive employment at 1, 2, and 5 years postinjury., Results: In the final employment prediction models, posttraumatic amnesia duration was the most important predictor of employment in each outcome year. Additional variables consistently contributing were age, preinjury education, productivity, and occupational category. Generally, individuals spending fewer days in posttraumatic amnesia, who were competitively employed preinjury, and more highly educated had better outcomes. Predictability in test data sets ranged from a C-statistic of 0.72 (year 5; confidence interval: 0.68-0.76) to 0.77 (year 1; confidence interval: 0.74-0.80)., Conclusion: An easy-to-use decision tree tool was created to provide prognostic information on long-term competitive employment outcomes in individuals with moderate to severe closed TBI. Length of posttraumatic amnesia, a clinical marker of injury severity, and preinjury education and employment status were the most important predictors.

Study Objective: To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors., Methods: This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries., Results: The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support., Conclusion: Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Chronic pain is a highly prevalent and potentially disabling condition in Veterans who have had a traumatic brain injury (TBI) and access to non-pharmacological pain treatments such as cognitive behavioral therapy is limited and variable. The purpose of this randomized controlled trial (RCT) is to evaluate the efficacy of a telephone-delivered cognitive behavioral therapy (T-CBT) for pain in Veterans with a history of TBI., Methods: Veterans with a history of TBI and chronic pain of at least six months duration (N = 160) will be randomized to either T-CBT or a telephone-delivered pain psychoeducational active control condition (T-Ed). The eight-week T-CBT intervention builds on other efficacious CBT interventions for chronic pain in the general population but is novel in that it is conducted via telephone and adapted for Veterans with a history of TBI. Outcome variables will be collected pre, mid-, and post-treatment, and 6 months following randomization (follow-up)., Projected Outcomes: In addition to evaluating the effects of the interventions on pain intensity (primary outcome), this study will determine their effects on pain interference, sleep, depression, and life satisfaction. We will also examine potential moderators of treatment outcomes such as cognition, PTSD, and alcohol and drug use. This non-pharmacologic one-on-one therapeutic intervention has the potential to reduce pain and pain-related dysfunction, improve access to care, and reduce barriers associated with geography, finances, and stigma, without the negative effects on physical and cognitive performance and potential for addiction as seen with some pharmacologic treatments for pain. This trial is registered at ClinicalTrials.gov, protocol NCT01768650., (Copyright © 2018 Elsevier Inc. All rights reserved.)

For patients surviving serious traumatic brain injury (TBI), families and other stakeholders often desire information on long-term functional prognosis, but accurate and easy-to-use clinical tools are lacking. We aimed to build utilitarian decision trees from commonly collected clinical variables to predict Glasgow Outcome Scale (GOS) functional levels at 1, 2, and 5 years after moderate-to-severe closed TBI. Flexible classification tree statistical modeling was used on prospectively collected data from the TBI-Model Systems (TBIMS) inception cohort study. Enrollments occurred at 17 designated, or previously designated, TBIMS inpatient rehabilitation facilities. Analysis included all participants with nonpenetrating TBI injured between January 1997 and January 2017. Sample sizes were 10,125 (year-1), 8,821 (year-2), and 6,165 (year-5) after cross-sectional exclusions (death, vegetative state, insufficient post-injury time, and unavailable outcome). In our final models, post-traumatic amnesia (PTA) duration consistently dominated branching hierarchy and was the lone injury characteristic significantly contributing to GOS predictability. Lower-order variables that added predictability were age, pre-morbid education, productivity, and occupational category. Generally, patient outcomes improved with shorter PTA, younger age, greater pre-morbid productivity, and higher pre-morbid vocational or educational achievement. Across all prognostic groups, the best and worst good recovery rates were 65.7% and 10.9%, respectively, and the best and worst severe disability rates were 3.9% and 64.1%. Predictability in test data sets ranged from C-statistic of 0.691 (year-1; confidence interval [CI], 0.675, 0.711) to 0.731 (year-2; CI, 0.724, 0.738). In conclusion, we developed a clinically useful tool to provide prognostic information on long-term functional outcomes for adult survivors of moderate and severe closed TBI. Predictive accuracy for GOS level was demonstrated in an independent test sample. Length of PTA, a clinical marker of injury severity, was by far the most critical outcome determinant.

Background: Identification and management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Recent meta-analyses highlight sleep disturbance and sleep disorders following TBI (Mathias & Alvaro, 2012). Improving the recognition and treatment of sleep disorders in TBI should be a central focus of rehabilitation. The Traumatic Brain Injury Model System (TBIMS) has created an infrastructure allowing multi-center investigations into sleep dysfunction in those who have had a moderate to severe TBI and received inpatient rehabilitation., Objective: This paper will describe the 1) infrastructure used to advance sleep dysfunction/disorders research following TBI, 2) preliminary findings from these studies, and 3) repository of data which can be accessed for secondary analyses by investigators outside of the TBIMS infrastructure., Methods: Two internal mechanisms allow investigators at TBIMS sites to collaborate on projects of shared interest: Research Modules and Special Interest Groups (SIG)., Results: To date, five studies have resulted from the TBIMS collaborative process focusing on insomnia, circadian disruption, and sleep apnea., Conclusions: Future directions for the SIG include continued development of available knowledge and understanding of the multidimensional factors that contribute to TBI-related sleep disturbance, optimal assessment tools, effectiveness of available treatments, and treatment compliance in this population.

Headache is one of the most frequently reported symptoms following traumatic brain injury (TBI). Little is known about how these headaches change over time. We describe the natural history of headache in individuals with moderate to severe TBI over 5 years after injury. A total of 316 patients were prospectively enrolled and followed at 3, 6, 12, and 60 months after injury. Individuals were 72% male, 73% white, and 55% injured in motor vehicle crashes, with an average age of 42. Pre-injury headache was reported in 17% of individuals. New or worse headache prevalence remained consistent with at least 33% at all time points. Incidence was >17% at all time points with first report of new or worse headache in 20% of participants at 60 months. Disability related to headache was high, with average headache pain (on 0-10 scale) ranging from 5.5 at baseline to 5.7 at 60 months post-injury, and reports of substantial impact on daily life across all time points. More than half of classifiable headaches matched the profile of migraine or probable migraine. Headache is a substantial problem after TBI. Results suggest that ongoing assessment and treatment of headache after TBI is needed, as this symptom may be a problem up to 5 years post-injury.

Objectives: We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma., Methods: Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend., Results: We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly ( P < .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%)., Conclusions: The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

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.)