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Background: In 2009, Gary and colleagues reviewed prior research examining racial and ethnic differences in outcomes after traumatic brain injury (TBI). Over the past 15 years, advances in research and changes in the demographic composition of the United States warrant a comprehensive understanding of racial and ethnic disparities after TBI., Objective: A systematic review will be conducted to examine racial and ethnic differences in TBI outcomes from 2009 to 2023., Methods: Preliminary searches and study screening processes will identify relevant English-language articles published from January 2009 to December 2023 using the CINAHL, Gale OneFile, PsycINFO (Ovid), and PubMed electronic databases. Relevant articles will include quantitative or mixed method approaches, involve individuals with TBI or their caregivers, and compare 2 or more groups by race or ethnicity on post-TBI outcomes. Quality will be assessed using the Newcastle-Ottawa Scale. This systematic review protocol was developed following PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. Results will be summarized, and a subgroup analysis may be conducted based on demographics (eg, age, gender, or sex)., Results: We have already identified abstracts using the search strategy for all 4 of the included electronic databases. We recently updated the search and will begin abstract screening of the additional abstracts identified from the last search completed in January 2024. This systematic review is anticipated to be completed by fall 2024, and its findings will be disseminated to the scientific community, persons with TBI, caregivers, and the lay audience., Conclusions: This systematic review will advance our understanding regarding outcome disparities among minoritized individuals with TBI, examine progress over the past 15 years in minimizing barriers encountered by these racial and ethnic groups, and provide professionals with a roadmap illustrating existing gaps in rehabilitation care, making way for further development and implementation of evidence-based interventions to improve health equity in TBI outcomes., Trial Registration: PROSPERO CRD42023394529; https://tinyurl.com/53mtcz9b., International Registered Report Identifier (irrid): PRR1-10.2196/58763., (©Monique R Pappadis, Kelli G Talley, Patricia Garcia, Caitlin R Aguirre, Chinedu K Onwudebe, Michelle Smith, Anthony H Lequerica. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 03.10.2024.)

Background Little is known about health literacy in traumatic brain injury (TBI) survivors. The aims of this study were to compare health literacy in individuals with TBI with that of a control group; to examine the association between health literacy in individuals with TBI and demographic, injury, and cognitive factors; and compare the relationship between health literacy and physical and mental health outcomes. Methods A cross-sectional observational study design was used. Adults (≥18years) were recruited from an outpatient research centre in Victoria, Australia. There were 209 participants with a complicated mild to severe TBI at least 1year previously (up to 30years 6months) and 206 control participants. Results Individuals with TBI did not have poorer health literacy than controls (IRR=1.31, P =0.102, CI95% [0.947, 1.812]). Further analysis could not be completed due to the highly skewed Health Literacy Assessment Using Talking Touchscreen Technology - Short Form (Health LiTT-SF) data. Conclusion Health literacy performance in individuals with TBI was not significantly different to controls. Premorbid education may provide a critical cognitive reserve upon which TBI survivors can draw to aid their health literacy. These findings are specific to the Health LiTT-SF measure only and require replication using more comprehensive health literacy measures in culturally diverse samples.

Objective: To (1) characterize lifetime mild traumatic brain injury (TBI) exposures among male and female US military service members and Veterans (SMVs) and (2) evaluate sex-related differences in mild TBI exposures., Setting: Clinical research laboratory., Participants: Participants were enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) Prospective Longitudinal Study., Design: Cross-sectional., Main Measures: Lifetime history of mild TBI was measured via structured interview. All mild TBI characteristics were collected as part of this interview, including total lifetime number; environment (deployment vs. non-deployment); timing of injury (relative to military service and age); and mechanism of injury (blast-related vs. non-blast)., Results: Most participants (n = 2323; 87.5% male; 79.6% Veteran) reported ≥1 lifetime mild TBI (n = 1912; 82%), among whom, many reported ≥2 lifetime mild TBIs. Female SMVs reported fewer total lifetime mild TBIs than male participants (P < 0.001), including fewer deployment-related (P < 0.001) and non-deployment (P < 0.001) mild TBIs. There were significant sex differences for total number of mild TBIs sustained before (P = 0.005) and during (P < 0.001) military service but not after separation from military service (P = 0.99). Among participants with a lifetime history of mild TBI, female SMVs were less likely to report ≥2 mTBIs (P = 0.003); however, male SMVs were more likely to report a mild TBI during military service (P = 0.03), including combat-related mild TBI (P < 0.001) and mild TBI involving blast (P < 0.001)., Conclusions: These findings inform clinical and research efforts related to mild TBI in US military SMVs. It may not be sufficient to simply measure the total number of mild TBIs when seeking to compare clinical outcomes related to mild TBI between sexes; rather, it is important to measure and account for the timing, environment, and mechanisms associated with mild TBIs sustained by female and male SMVs., Competing Interests: Conflicts of Interest: Samuel R. Walton: Dr Walton reports separate funding support from the DoD & VA for projects related to the LIMBIC-CENC study; honorarium and conference travel support from the National Athletic Trainers’ Association and UCLA; serves in unpaid leadership roles with the World Federation of Athletic Training and Therapy (WFATT) and the Concussion in Sport Group (CISG); Jessie R. Oldham: Dr. Oldham receives support from the Thrasher Research Fund and National Institute of Arthritis and Musculoskeletal Skin Diseases (8K12AR084233-03); Benjamin L. Brett: Dr. Brett reports funding support from the NIA and NINDS, as well as honoraria and travel support as conference presentations; Elisabeth A. Wilde: Dr. Wilde receives grant funding support from the US Department of Veterans Affairs and the Department of Defense (related to this work and cited below) and from the National Institutes of Health (NINDS), and Vielight, Inc. (unrelated to this work); Rosemay A. Remigio-Baker:Dr. Remigio-Baker is a contractor from Compass Government Solutions that support the Traumatic Brain Injury Center of Excellence; Mary J. Pugh: Dr. Pugh reports separate funding support from the DoD & VA for projects not related to the LIMBIC-CENC study; Randel L. Swanson: Dr. Swanson reports separate funding support from the VA for a project related to the LIMBIC-CENC study and funding from the DoD and VA for projects not related to the LIMBIC-CENC study. Dr. Swanson was supported, in part, by the United States Department of Veterans Affairs Rehabilitation Research and Development Service under Award Number IK2 RX00365; Monique R. Pappadis: Receives grant funding support from the NIH/NIA (K01AG065492), NIMHD (L60MD009326L), and NIDILRR (90DPTB0025). Tara A. Austin, Olivia D. Cetin, Landon B. Lempke, Zhining Ou, Sreekanth Kamineni, Sarah L. Martindale, Maya E. O’Neil, David X. Cifu, and William C. Walker: declared no conflict of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Our study investigated whether changes in physical activity due to COVID-19 mediate the association between quarantine or hospitalization due to COVID-19 and COVID-19 life impact score. A total of 154 participants (0.23%) were quarantined or hospitalized due to COVID-19. There were mediating effects of changes in physical activity due to COVID-19 (β = -1.63, 95% confidence interval = -0.77 to -2.42). This study suggests that measures to minimize lifestyle changes during the pandemic are required to reduce negative consequences.

Context: There is strong evidence that racial and ethnic disparities exist in multiple arenas of health and wellness. The causes of racial and ethnic differences in health care are multidimensional; one factor that may affect injury/illness communication, interactions, and outcomes is patient-provider racial and ethnic concordance. At present, it is unclear what role patient-provider racial and ethnic concordance and discordance plays in facilitating concussion care for collegiate athletes., Objective: To investigate the presence of athlete-athletic trainer (AT) racial and ethnic concordance and discordance among diagnosed concussion cases and examine if racial and ethnic concordance and discordance influences time (in days) until diagnosis, symptom resolution, or return-to-sport clinical milestones in collegiate athletes., Design: Retrospective cohort study., Setting: Collegiate athletics., Patients or Other Participants: A total of 694 concussion cases (38.6% [n = 268] sustained by women, 61.4% [n = 426] sustained by men) that occurred within the 2015-2016 through 2019-2020 sport seasons at 9 institutions., Main Outcome Measure(s): The number of days from the date of injury to diagnosis, symptom resolution, and return to sport and from the date of diagnosis to symptom resolution and return to sport., Results: Overall, 68.4% (n = 475) of concussion cases had patient-provider racial and ethnic concordance, and 31.6% (n = 219) were discordant. All concordant pairs included a White athlete and White AT. Time to diagnosis differed between the concordant and discordant groups (median [interquartile range] = 1 [0-2] versus 0 [0-1], respectively) only in the model adjusted for sex, sport type, and availability of an AT (odds ratio [95% CI] = 1.46 [1.07-1.85]). There were no other group differences., Conclusions: One-third of concussion cases had athlete-AT racial and ethnic discordance. Although this group was diagnosed with a concussion 1 day sooner than the concordant group, no differences were observed for any concussion recovery milestones. These findings suggest that patient-provider racial and ethnic concordance may play a minor role in concussion recognition or reporting but not necessarily in the management and recovery thereafter., (© by the National Athletic Trainers’ Association, Inc.)

We examined the relationship between vision impairment (VI) and new-onset frailty among non-frail Mexican American older adults (≥70 years) at baseline and determined the differential impact of VI on each frailty criteria. Data were from an 18-year prospective cohort from the Hispanic Established Population for the Epidemiologic Study of the Elderly (1998/1999, N = 1072 to 2016, N = 175). Frailty was defined as ≥3 criteria: unintentional weight loss of >10 pounds, weakness, exhaustion, low physical activity, and slowness. VI was defined as difficulty in recognizing a friend at arm's length's away, across the room, or across the street. We found that participants with VI (near or distant) and distant VI had greater odds of frailty (near or distant VI, OR = 1.89, 95% CI = 1.30-2.73 and distant VI, OR = 1.95, 95% CI = 1.34-2.86, respectively) after controlling for covariates over time. Early screening (optimal management) of VI may prevent or delay onset of frailty among older Mexican Americans., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To characterize health literacy among individuals with traumatic brain injury (TBI) at least a year postinjury and to explore its relationship to sociodemographic variables, injury severity, and cognition., Setting: Community following discharge from inpatient rehabilitation., Participants: In total, 205 individuals with complicated mild to severe TBI who completed follow-up as part of a national longitudinal study of TBI and completed a web-based health literacy measure., Design: Multicenter, cross-sectional, observational study., Main Measures: Health Literacy Assessment Using Talking Touchscreen Technology., Results: Thirty-one percent of the sample demonstrated marginal/inadequate health literacy; 69% demonstrated adequate health literacy. A higher proportion of non-Hispanic White adults had adequate health literacy than non-Hispanic Black and Hispanic adults. Individuals with greater than a high school education were more likely to have adequate health literacy than those with a high school education or less. Better executive functioning performance was related to adequate health literacy. Better episodic memory performance was related to adequate health literacy, but only for those with complicated mild to moderate injury., Conclusions: A substantial proportion of individuals with TBI have marginal/inadequate health literacy, which may impact their understanding, appreciation, and use of health-related information and recommendations. While low health literacy may be preexisting, directly related to TBI, or a combination of both, it should be screened and considered by professionals when communicating with persons with TBI. Healthcare providers should tailor their communication approaches and presentation of health information, particularly for those with low health literacy., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI., Design: An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI., Method: A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2)., Results: A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning., Conclusions: Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.)

Objective: To examine the associations between health literacy and health outcomes among individuals with traumatic brain injury (TBI) at least a year post-injury., Setting: Community following discharge from inpatient rehabilitation., Participants: A total of 205 individuals with complicated mild to severe TBI who completed a TBI Model Systems National Database follow-up interview and a web-based health literacy measure., Design: A multicenter, cross-sectional, observational study., Main Measures: The Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT), number of comorbid conditions (Medical and Mental Health Comorbidities Interview [MMHCI]), perceived physical and mental health (PROMIS Global Physical and Mental Health subscales), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7)., Results: After controlling for sociodemographic, injury, cognition, and time post-injury, adequate health literacy was associated with higher odds of greater perceived physical health compared with participants with marginal/inadequate health literacy (odds ratio = 4.10; CI = 1.52-11.70]. Participants with inadequate/marginal health literacy had 3.50 times greater odds of depression (PHQ-9 ≥ 10) compared with those with adequate health literacy. Participants 45 years and older reported a greater number of MMHCI physical health conditions, but fewer MMHCI mental health conditions and GAD-7 anxiety symptoms compared with those who were younger. Non-Hispanic White participants and those with mild/moderate TBI were more likely to report a greater number of MMHCI mental health conditions compared with non-Hispanic Black participants or those with severe TBI. Greater time post-injury was associated with greater number of chronic physical and mental health conditions, and less odds of good-to-excellent perceived global mental health., Conclusions: Inadequate health literacy is associated with worse perceived physical health and greater depressive symptoms among adults with TBI. Greater efforts are needed to explore the mechanisms by which health literacy influences chronic disease management and mental health after TBI to improve postinjury health status and outcomes, particularly among those with limited health literacy skills., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose of this study was to characterize the associations of international student status and native language on time (in days) with the date of injury to (i) diagnosis, (ii) symptom resolution, and (iii) return to sport., Methods: Utilizing data from a cross-sectional cohort of 1,044 concussion cases from LIMBIC MATARS member institutions ( n  = 11) in the US, we conducted two, matched case-control designs. Cases were divided into two groups: (i) international ( n  = 32) or domestic students ( n  = 32) and (ii) English as an Additional Language (EAL) speakers ( n  = 18) or Native English language speakers ( n  = 18). Both groups were individually matched to their respective controls based on gender, age, sport, and preexisting health conditions., Results: There were no significant differences in days from injury to diagnosis ( p  = 0.94), symptom resolution ( p  = 0.64), or return to sport ( p  = 0.15) between international and domestic athletes. EAL speakers experienced symptom resolution approximately 7.5 days sooner (Md = 4.50; IQR = 4.00, 8.00) than Native English language speakers (Md = 12.00; IQR = 7.00, 21.00, p  = 0.01)., Conclusions: Our findings suggest that native language is associated with symptom resolution in collegiate athletes. Healthcare professionals should consider barriers related to native language that may impact symptom reporting and the overall injury experience of diverse collegiate athletes.

Using 100% Medicare data files, this study explored whether primary elder mistreatment (EM) diagnosis, EM type, and facility type were associated with 3-year mortality and 1-year unplanned hospital readmission among older patients diagnosed with EM with hospital discharge from 10/01/2015 through 12/31/2018 ( n = 11,023). We also examined outcome differences between older patients diagnosed with EM and matched non-EM patient controls. Neglect by others was the most common EM diagnosis. Three-year mortality was 56.7% and one-year readmission rate was 53.8%. Compared to matched non-EM patient controls, older EM patients were at an increased risk of mortality and readmission. Among patients diagnosed with EM, patients with a secondary (vs. primary) diagnosis and those discharged from a skilled nursing facility (vs. acute hospital) were at an increased risk for both mortality and readmission. Compared to other EM types, patients diagnosed with neglect by others had a greater risk for mortality following discharge., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Untreated, urgency urinary incontinence (UUI) and overactive bladder (OAB) can precipitate a vicious cycle of decreasing physical activity, social isolation, fear of falling, and falls. Structured behavioral interventions and medications are common initial treatment options, but they elicit their effects through very different mechanisms of action that may influence fall-related outcomes differently. This study will determine the feasibility of conducting a comparative effectiveness, three-arm, mixed methods, randomized clinical trial of a behaviorally based pelvic floor muscle training (PFMT) intervention versus two recent drug options in older women with UUI or OAB who are also at increased risk of falling., Methods: Forty-eight women 60 years and older with UUI or OAB who screen positive for increased fall risk will be recruited through the urogynacology and pelvic health clinics of our university health system. Participants will be randomly assigned to one of three 12-week treatment arms: (1) a course of behavioral and pelvic floor muscle training (PFMT) provided by physical therapists; (2) the beta-3 agonist, mirabegron; and (3) the antimuscarinic, trospium chloride. Study feasibility will be established through objective metrics of evaluability, adherence to the interventions, and attrition. We will also assess relevant measures of OAB symptom severity, quality of life, physical activity, incident falls, and concern about falling., Discussion: The proposed research seeks to ultimately determine if linkages between reduction in UI symptoms through treatment also reduce the risk of falling in this patient population., Trial Registration: NCT05880862. Registered on 30 May 2023., (© 2024. The Author(s).)

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days ( n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups ( z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Objective: To determine if there were concussion diagnosis and recovery disparities between collegiate athletes with Black and White racial identities., Design: Retrospective cohort study., Methods: Concussion information was extracted from NCAA athlete medical files at LIMBIC MATARS member institutions from the 2015-16' to 2019-20' academic years. A total of 410 concussions from 9 institutions were included that provided all independent (i.e. racial identity of Black or White) and dependent variable information (i.e. dates of injury, diagnosis, symptom resolution, and return to sport) that were analyzed using Mann-Whitney U tests. The sample consisted of 114 (27.8%) concussions sustained by Black athletes and 296 (72.1%) sustained by White athletes., Results: The overall sample had a median of 0 days between injury occurrence to diagnosis, 7 days to symptom resolution, and 12 days to return to sport. No significant timing differences were observed for concussion diagnosis ( p  = .14), symptom resolution ( p  = .39), or return to sport ( p  = 0.58) between collegiate athletes with Black versus White racial identities., Conclusions: These findings may reflect equitable access to onsite sports medicine healthcare resources that facilitate concussion management in the collegiate sport setting. Future work should explore these associations with a larger and more diverse sample of collegiate athletes.

Background: An urgent educational need is to examine the current gaps in cultural competence/humility, diversity, equity, inclusion, and accessibility (DEIA) that may significantly affect the teaching and learning environments among students/faculty. This mixed-methods study examined the current level of cultural competemility and perceptions of diversity, equity, and inclusion (DEI)-related challenges and recommendations among students/faculty of health professions., Methods: Students and faculty completed a survey including the Inventory for Assessing the Process of Cultural Competemility Among Healthcare Professionals (IAPCC-HCP©) and open-ended questions on their DEI perceptions and needs. Data were analyzed via descriptive statistics and independent t-tests. Qualitative data were coded using thematic content analysis., Outcomes: A total of 100 participants (64 students, 38 faculty) completed the survey. The majority identified as Caucasian or non-Hispanic White and female, and were satisfied with DEIA-related school-level initiatives and familiar with how to use pronouns to reflect all genders. Compared to students, faculty scored slightly higher, although not significantly, in five of six domains, including Cultural Humility, Cultural Awareness, Culture Skill, Cultural Encounters and Cultural Desire. Participants shared their need to address: 1) DEIA gaps in knowledge and Schools of Health Professions curriculum; 2) involvement of students; 3) racism, biases, and discrimination; and 4) recognition of underrepresented groups. Training needs were in the areas of 1) DEIA assessment and training for students and faculty; 2) DEIA school activities; 3) DEIA-informed policies; and 4) modifications to clinical education., Conclusion: The faculty more than students expressed the need to enhance their DEI and cultural knowledge. Our findings can guide further development of educational activities and school-level DEI initiatives in schools of health professions.

Background: An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90-day community residence and readmission., Methods: We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short-term and long-term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term nursing home (NH), and hospice were identified. The primary outcome was 90-day community residence. Our secondary outcome was 90-day, all-cause readmission., Results: In Texas, 26,985 Medicare fee-for-service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08-1.25]), Hispanic ethnicity (OR = 2.01 [1.80-2.25]), "other" race (OR = 2.19 [1.73-2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40-1.62]) were associated with increased likelihood of 90-day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate-to-severe injury severity were associated with decreased likelihood of 90-day community residence. Being non-Hispanic Black (HR = 1.33 [1.20-1.46]), discharge to SNF (HR = 1.56 [1.48-1.65]) or IRF (HR = 1.49 [1.40-1.59]), having prior PCP (HR = 1.23 [1.17-1.30]), dual eligibility (HR = 1.11 [1.04-1.18]), and prior TBI diagnosis (HR = 1.05 [1.01-1.10]) were associated with increased risk of 90-day readmission. Female sex and "other" race were associated with decreased risk of 90-day readmission., Conclusions: Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90-day readmission following hospital discharge. Future studies should explore how having a PCP influences post-hospital outcomes in chronic care management of older patients with TBI., (© 2023 The American Geriatrics Society.)

Background: Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries., Methods: Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes., Results: Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores., Conclusions: Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults., (© 2023 The American Geriatrics Society.)

Objective(s): To examine the breadth of education or training on the consequences of traumatic brain injury (TBI) for children and adolescents with TBI and their families/caregivers., Methods: Systematic scoping review of literature published through July 2018 using eight databases and education, training, instruction, and pediatric search terms. Only studies including pediatric participants (age <18) with TBI or their families/caregivers were included. Six independent reviewers worked in pairs to review abstracts and full-text articles independently, and abstracted data using a REDCap database., Results: Forty-two unique studies were included in the review. Based on TBI injury severity, 24 studies included persons with mild TBI (mTBI) and 18 studies focused on moderate/severe TBI. Six studies targeted the education or training provided to children or adolescents with TBI. TBI education was provided primarily in the emergency department or outpatient/community setting. Most studies described TBI education as the main topic of the study or intervention. Educational topics varied, such as managing TBI-related symptoms and behaviors, when to seek care, family issues, and returning to work, school, or play., Conclusions: The results of this scoping review may guide future research and intervention development to promote the recovery of children and adolescents with TBI.

Objective: To examine the relationship between payer source for acute rehabilitation, residential median household income (MHI), and outcomes at rehabilitation discharge after traumatic brain injury (TBI)., Setting: Acute inpatient rehabilitation facilities., Participants: In total, 8558 individuals enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who were admitted to inpatient rehabilitation between 2006 and 2019 and were younger than 64 years., Design: Secondary data analysis from a multicenter longitudinal cohort study., Main Measures: Payer source was divided into 4 categories: uninsured, public insurance, private insurance, and workers' compensation/auto. Relationships between payer source with residential MHI, rehabilitation length of stay (RLOS), and the FIM Instrument at discharge were examined. Covariates included age, injury severity, FIM at admission, and a number of sociodemographic characteristics including minority status, preinjury limitations, education level, and employment status., Results: Individuals with workers' compensation/auto or private insurance had longer RLOS than uninsured individuals or those with public insurance after controlling for demographics and injury characteristics. An adjusted model controlling for demographics and injury characteristics showed a significant main effect of payer source on FIM scores at discharge, with the highest scores noted among those with workers' compensation/auto insurance. The main effect of payer source on FIM at discharge became nonsignificant after RLOS was added to the model as a covariate, suggesting a mediating effect of RLOS., Conclusion: Payer source was associated with preinjury residential MHI and predicted RLOS. While prior studies have demonstrated the effect of payer source on long-term outcomes due to lack of inpatient rehabilitation or quality follow-up care, this study demonstrated that individuals with TBI who are uninsured or have public insurance may be at risk for poorer functional status at the point of rehabilitation discharge than those with private insurance, particularly compared with those with workers' compensation/auto insurance. This effect may be largely driven by having a shorter length of stay in acute rehabilitation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To explore the impact of traumatic brain injury (TBI) on the quality of life (QoL) and self-concept of Spanish-speaking U.S. Hispanic immigrants with TBI., Materials and Methods: A prospective, qualitative study conducted in a county level I trauma center and community. Semi-structured interviews on QoL and self-concept following TBI were conducted with 24 Spanish-speaking U.S. Hispanic immigrants with TBI living in the community at least 6 months following injury., Results: Perceived facilitators of QoL included faith, hopefulness in recovery, empathy for others, and support from others. Perceived barriers to QoL mentioned were symptoms/consequences of injury, employment/financial changes, loss of independence, fear/uncertainty, stigma/shame, lack of medical care, and decreased social integration. Participants described their self-concept after TBI as either a maintained self or loss of self. Those who viewed themselves differently reported physical and emotional changes, gender role conflict, loss of self-worth, and total loss due to the TBI., Conclusions: Spanish-speaking U.S. Hispanic immigrants held a strong faith and positive outlook after TBI in spite of the significant barriers to recovery. A need exists for programs to support creatively the recovery of Spanish-speaking U.S. Hispanic immigrants with limited access to care and resources.IMPLICATIONS FOR REHABILITATIONSpanish-speaking U.S. Hispanic immigrants may experience significant barriers to care following traumatic brain injury (TBI), such as access to rehabilitation services and follow-up care.Rehabilitation professionals should consider the importance of faith and encourage positive thinking and social support when working with Spanish-speaking U.S. Hispanic immigrants on how to cope with TBI-related challenges.Access to Spanish-speaking rehabilitation professionals, translators and Spanish language educational materials could help reduce language-related barriers to recovery among Spanish-speaking U.S. immigrants with TBI.Rehabilitation facilities should develop partnerships with community-based organizations serving the uninsured or underinsured to address the access to rehabilitation and medical needs of Spanish-speaking U.S. immigrants with TBI.

Background: It is important for clinicians to have a better understanding of stroke survivor's goals. Important performance analysis (IPA) is a tool that could be utilized to identify goal priorities in rehabilitation., Objectives: To examine the utility of the IPA method to identify goal priorities in a diverse group of community dwelling stroke survivors., Methods: Thirty-eight stroke survivors completed private structured interviews and were asked to rate their perceived importance and performance of 37 goal areas. Important-performance analysis (IPA) was utilized to determine goal priorities for the overall sample. Different IPA methods used to identify goal priorities were compared. Goal priorities were also compared by age (dichotomized as <65 and ≥65 years) and sex (male or female)., Results: The IPA method effectively separated the goals into the four quadrants, and distinguished which goals were a priority for the sample of stroke survivors. The five goals that were consistently identified as a focus area were: hand function, driving, balance, memory, and arm strength. Men rated mood control as more important than women ( p = .046). The two goals rated as being more important for those older than 65 were home accessibility ( p = .008) and skin health ( p < .001)., Conclusions: Stroke survivors continue to have goals related to their stroke recovery in the years after their stroke. Both current performance as well as perceived importance should be considered during goal discussions with stroke survivors. IPA can help identify goal priorities in this population.

This study examined the association between achieving the recommended physical activity level and quality of life after controlling for depression. Health information from adults aged 65 years and older, who had participated in the seventh 2018 Korea National Health and Nutrition Examination Survey, was used. Five covariate adjustment models were used to derive robust estimates of the association between physical activity practice levels, depression, and older adults' quality of life. A total of 1,336 older adults was extracted from the seventh 2018 Korea National Health and Nutrition Examination Survey, and 31% of the older adults achieved the recommended physical activity level, whereas 69% did not. We found that the achievement of physical activity practice levels is significantly associated with the quality of life of the older adults (β = 0.024-0.031, all p < .05). Our results could be used for advocating for welfare policy changes that promote physical activity to prepare for the upcoming super-aging society.

Objective: To examine the relationship between primary language and participation outcomes in English- and Spanish-speaking persons with complicated mild to severe traumatic brain injury (TBI) at 1 year post-injury., Setting: Community following discharge from inpatient rehabilitation., Participants: A total of 998 Hispanic participants with outcomes available at year 1 follow-up; 492 (49%) indicated English as their primary language and 506 (51%) indicated Spanish as their primary language., Design: Prospective, multicenter, cross-sectional, observational cohort study., Main Measures: Community participation at 1 year post-injury was assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out and About, Productivity, and Social Relations., Results: Unadjusted group comparisons showed better participation outcomes for English versus Spanish speakers for all PART-O domains and for the Balanced Total score. After controlling for relevant covariates, English-speaking participants had significantly better PART-O Balanced Total scores and better scores on the Social Relations domain, although effect sizes were small., Conclusions: Hispanic persons with TBI whose primary language is Spanish may require greater assistance integrating socially back into their communities after TBI. However, potential cultural differences in value placed on various social activities must be considered. Potential cultural bias inherent in existing measures of participation should be investigated in future studies., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Recent cancer survivors (<2 years post-diagnosis) report poorer general health and physical weakness compared to long-term cancer survivors (≥2 years post-diagnosis), but differences in functional limitations are unknown. It is unclear which daily tasks are more difficult for recent versus long-term survivors. We aimed to examine differences in functional performances across cancer recovery phases as potential targets for functional impairment screening., Method: The cohort consisted of adults with a cancer history in the 2015 National Health Interview Survey ( n =2372). Multivariate logistic regression models were used to estimate the odds of having difficulty in health-related outcomes across the cancer recovery phases (recent versus long-term)., Results: Most subjects were long-term survivors (84.9%). Recent survivors were more likely to have difficulty in work, mobility-related daily tasks and social participation compared to long-term survivors. No differences were found in basic activities of daily living, cognition and emotional functioning between the groups., Conclusion: While recent cancer survivors were independent in basic daily tasks, they had difficulties in performing daily tasks that required a high level of physical function. Clinicians, especially occupational therapists, should prioritize evaluating physical functioning to guide intervention planning for recent cancer survivors., Competing Interests: Declaration of conflicting interests The authors have no conflict of interest, including financial conflict, to declare.

Objective: To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature., Data Sources: Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA., Study Selection: Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded., Data Extraction: Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer., Data Synthesis: Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms., Conclusions: Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to investigate sex differences and the impact of social living situation on individual functional independence measure outcomes after stroke rehabilitation., Design: A retrospective observational study using Medicare fee-for-service beneficiaries (N = 125,548) who were discharged from inpatient rehabilitation facilities in 2013 and 2014 after a stroke. Discharge individual functional independence measure score, dichotomized as ≥5 and <5, was the primary outcome measure. A two-step generalized linear mixed model was used to measure the effect of sex on each functional independence measure item while controlling for many clinical and sociodemographic covariates., Results: After adjusting for sociodemographic and clinical factors, females had higher odds of reaching a supervision level for 14 of 18 functional independence measure items. Males had higher odds of reaching a supervision level on 2 of 18 functional independence measure items. Individuals who lived alone before their stroke had higher odds of reaching a supervision level than individuals who lived with a caregiver or with family for all functional independence measure items., Conclusions: When sociodemographic and clinical factors are controlled, females are more likely to discharge from inpatient rehabilitation at a supervision level or better for most functional independence measure items. Individuals who live alone before their stroke have higher odds of discharging at a supervision level or better.

A growing number of individuals are living with chronic traumatic brain injury. As these individuals and their families attempt to reintegrate into their communities, several ethical questions arise for clinicians and researchers. These include issues around alignment of perspectives and priorities, as well as responsibilities for ongoing treatment, education, community outreach, and research. An action plan for addressing these questions is outlined.

Objectives: Few studies have explored the lived experiences of chronic cognitive and mood symptoms following stroke using a racially/ethnically diverse sample. Therefore, we aimed to explore the perceptions of chronic post-stroke cognition and mood symptoms and goals among a racially/ethnically diverse sample of community-dwelling adults aging with stroke. Method: This qualitative study using mixed-methods analysis included semi-structured interviews regarding perceived post-stroke cognitive and mood symptoms among community-dwelling stroke survivors at least one-year post stroke. Transcripts were subjected to thematic content analysis, and differences in theme usage patterns by age, gender, race/ethnicity, and post-acute rehabilitation setting were assessed using an inferential clustering technique. Results: The majority of participants (93%) reported cognition-related themes, including language and communication, memory, thinking abilities, comprehension, visual-spatial processing, and cognitive assessments and training. Nearly half of participants mentioned mood-related themes, including depression, aggression and anger, mood fluctuations, anxiety, and psychological services and medication. Nearly half reported an unmet need for cognition or mood-related treatment. Inferential clustering analysis revealed that older participants reported a different pattern of cognitive and mood symptoms than those aged younger than 65 ( p  = 0.02). Older adults were more likely to describe post-stroke language/communication changes, while younger adults described post-stroke mood changes. Conclusion: Stroke survivors experienced cognitive and mood-related symptoms beyond one-year post stroke, which has implications for long-term assessment and management. Incorporation of continued symptom monitoring into existing community-based services is needed to address chronic cognitive and mood symptoms affecting the quality of life of persons with stroke.

Background and Purpose: Patients and caregivers have not typically been involved in the selection of a post-acute care (PAC) provider. In 2015, the Centers for Medicare & Medicaid Services proposed the need to involve patients and their families during discharge planning. Engaging patients in rehabilitation decisions encourages shared decision making among patients and their clinicians. The purpose of this study was to examine stroke survivors' perspectives on their involvement in selecting a PAC provider and their goal setting and their satisfaction with the rehabilitation stay and their discharge advice for stroke survivors, prior to 2015., Methods: This qualitative study utilized semistructured interviews. Thematic content analysis was performed on interviews involving 18 stroke survivors (mean age = 68 years) related to their involvement in planning for their inpatient rehabilitation facility or skilled nursing facility stay, goal setting, and discharge needs., Results: More than half the participants were not involved in the selection of their PAC setting and believed that doctors made these decisions. Around two-fifths of stroke survivors reported that they were not involved in rehabilitation goal setting. Most patients were satisfied with their rehabilitation stay. When asked to recommend discharge topics for other stroke survivors, participants recommended additional information on health care services, interventions, and insurance coverage., Discussion and Conclusion: Despite recommendations to include stroke patients in PAC selection and goal setting, many former inpatient rehabilitation facility and skilled nursing facility patients report not being involved in either aspect of care.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A273).

Differences exist across breast cancer screening guidelines regarding frequency of screening and age of discontinuation for older women (≥70 years) at average risk for breast cancer. These differences highlight concerns about the benefits and harms of screening, and may negatively impact older women's ability to make informed screening decisions. This study examined preferences for communicating about screening mammography among racially/ethnically diverse, older women. In-depth interviews were conducted with 59 women with no breast cancer history. Non-proportional quota sampling ensured roughly equal numbers on age (70-74 years, ≥75 years), race/ethnicity (non-Hispanic/Latina White, non-Hispanic/Latina Black, Hispanic/Latina), and education (≤high school diploma, >high school diploma). Interviews were audio-recorded, transcribed, and analyzed using NVivo 10. Thematic analyses revealed that rather than being told to get mammograms, participants wanted to hear about the benefits and harms of screening mammography, including overdiagnosis. Participants recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants' age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography, and would prefer to learn this information through discussions with healthcare providers and multiple other formats.

Objective: This study explored the experiences and needs of older adults during and following Hurricane Ike., Method: Two focus group interviews were conducted among older adults who lived in or around Galveston Island before Hurricane Ike. Nine older adults (six women and three men) participated in two focus group sessions. These qualitative interviews were audio recorded, transcribed, and analyzed using thematic content analyses., Results: The findings of this study reveal the need for continuity in health care services, medications, psychological support, social and family support, community-level services, and information among older adults., Conclusions: The contribution of factors such as health care continuity and psychological support reinforces the importance of specific postdisaster resources to meet the needs of older adults following hurricanes. These results suggest the importance of designing hurricane preparedness guidelines specifically for older adults.

Approximately 800,000 people in the United States have a stroke annually. Up to two thirds of stroke survivors have some visual problems, which result in disability and can affect survivors' overall rehabilitation outcomes. Although some post-stroke visual impairments can be corrected and respond well to intervention, ocular signs can be subtle and may not be recognized or reported by the stroke survivor but rather by a vigilant caregiver. The purpose of this study was to explore the post-stroke visual concerns and consequences expressed by stroke survivors and caregivers. This study employed a qualitative design using semistructured interviews conducted with a convenience sample of stroke survivors and caregivers recruited from either a community support group or skilled nursing and long-term care facilities. Interviews were recorded and transcribed verbatim. Comparative content analysis was used to identify vision-related themes by two independent coders. All research team members completed quality checking of coding. Twenty participants (11 stroke survivors and 9 caregivers) expressed visual concerns or consequences following stroke: (1) eye movement problems, (2) perceptual issues, and (3) consequences of vision problems or issues, which affected their daily life/quality of life. Stroke survivors and caregivers reported receiving vision care from (1) eye doctors, (2) occupational therapists, and (3) other healthcare professionals. All vision care providers need to be observant of potential post-stroke visual concerns. Stroke survivors should have a thorough vision evaluation to optimize their independence in everyday activities and quality of life.

Resource facilitation (RF) has shown promise for improving return to work (RTW) after traumatic brain injury (TBI), but little is known about the RF needs of people recruited from acute trauma settings. In this descriptive study, we sought to track referral needs, describe problems in accessing state vocational rehabilitation (VR) services, and highlight the role of RF in overcoming these difficulties in 45 adults with complicated mild to severe TBI seeking RTW who were recruited from acute trauma care. Participants received a referral to the state VR agency, along with RF services for up to one year. Case coordinators (CCs) conducted biweekly assessments, provided referrals, and helped address problems in accessing services. On average 4.92 referrals were generated per participant; 91% required referrals. CCs made 44% of referrals, while physicians/other healthcare professionals generated 33% and VR counsellors generated 23%. CCs filled a gap in referring for financial and transportation difficulties. Two case studies illustrate implementation of the RF paradigm. RF provides systematic assessment and referral for services needed to facilitate utilisation of state VR services. Among persons with TBI recruited from acute trauma settings in the US, CCs provide referrals that are often not generated by other sources.

Objective: To investigate the contribution of race/ethnicity to retention in traumatic brain injury (TBI) research at 1 to 2 years postinjury., Setting: Community., Participants: With dates of injury between October 1, 2002, and March 31, 2013, 5548 whites, 1347 blacks, and 790 Hispanics enrolled in the Traumatic Brain Injury Model Systems National Database., Design: Retrospective database analysis., Main Measure: Retention, defined as completion of at least 1 question on the follow-up interview by the person with TBI or a proxy., Results: Retention rates 1 to 2 years post-TBI were significantly lower for Hispanic (85.2%) than for white (91.8%) or black participants (90.5%) and depended significantly on history of problem drug or alcohol use. Other variables associated with low retention included older age, lower education, violent cause of injury, and discharge to an institution versus private residence., Conclusions: The findings emphasize the importance of investigating retention rates separately for blacks and Hispanics rather than combining them or grouping either with other races or ethnicities. The results also suggest the need for implementing procedures to increase retention of Hispanics in longitudinal TBI research.

Objectives: Current research on the perceptions of overdiagnosis or overdetection of breast cancer has largely been conducted outside of the USA and with women younger than 70 years.Therefore, we explored older women's perceptions about the concept of overdetection of breast cancer and its influence on future screening intentions., Design: Mixed-methods analysis using purposive sampling based on race/ethnicity, age and educational level. Semistructured interviews, including two hypothetical scenarios illustrating benefits and harms of screening and overdetection, were analysed using inductive and deductive thematic approaches. An inferential clustering technique was used to assess overall patterns in narrative content by sociodemographic characteristics, personal screening preferences or understanding of overdetection., Setting: Houston/Galveston, Texas, USA., Participants: 59 English-speaking women aged 70 years and older with no prior history of breast cancer., Results: Very few women were familiar with the concept of overdetection and overtreatment. After the scenarios were presented, half of the women still demonstrated a lack of understanding of the concept of overdetection. Many women expressed suspicion of the concept, equating it to rationing. Women who showed understanding of overdetection were more likely to express an intent to discontinue screening, although 86% of the women stated that hearing about overdetection did not influence their screening decision. Themes identified did not differ by race/ethnicity, education, age or screening preferences. Differences were identified between women who understood overdetection and women who did not ( r =0.23, p<0.001)., Conclusions: Many older women did not understand the concept of overdetection, in addition to being suspicious of or resistant to the concept. Providing older women with descriptions of overdetection may not be sufficient to influence screening intentions., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Screening mammography is associated with reduced breast cancer-specific mortality; however, among older women, evidence suggests that the potential harms of screening may outweigh the benefits. We used a qualitative approach to examine the willingness of older women from different racial/ethnic groups to discontinue breast cancer screening., Methods: Women ≥70 years of age who reported having a screening mammogram in the past 3 years and/or reported that they intended to continue screening in the future were recruited for in-depth interviews. Participants who intended to continue screening were asked to describe how the following hypothetical scenarios would impact a decision to discontinue screening: health concerns or limited life expectancy, a physician's recommendation to discontinue, reluctance to undergo treatment, and recommendations from experts or governmental panels to stop screening. Semi-structured, face-to-face interviews were audio-recorded. Data coding and analysis followed inductive and deductive approaches., Results: Regardless of the scenario, participants (n = 29) expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were skeptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education., Conclusions: Among older women who planned to continue screening, intentions to continue breast cancer screening appear to be highly resilient and resistant to recommendations from physicians or expert/government panels., (Copyright © 2018 John Wiley & Sons, Ltd.)

Purpose: To explore the mobility-related preferences among stroke survivors and caregivers following post-acute rehabilitation at inpatient or skilled nursing facilities., Methods: In this cross-sectional study; semi-structured, qualitative interviews of stroke survivors (n = 24) and informal caregivers (n = 15) were conducted. The participants were recruited from the community., Results: Comparative content analysis was used to identify themes by two independent coders. The survivors (68 years) and caregivers (58 years) mentioned mobility-related consequences including inability to walk, balance, drive, and transfer; and increased falls. The survivors (63%) and caregivers (73%) also mentioned the use of assistive devices. The common rehabilitation activities included: walking (62%); followed by standing and mobility; strength and balance; and wheelchair skills. Some stroke survivors were dissatisfied as their rehabilitation was not patient-centered. Frequently mentioned outcome preferences by survivors were ability to walk (88%), move, and balance. They also wanted to acquire assistive devices to move independently. Caregivers were concerned with the survivor's safety and wanted them to drive (53%), prevent falls, have home accommodations, and transfer independently. Caregivers (40%) also expressed the importance of receiving realistic information., Conclusions: This study suggests a need to consider the stroke survivors' and caregivers' mobility outcome preferences to improve the patient-centered rehabilitation care. Implications for Rehabilitation Stroke survivors and caregivers tend to differ in their outcome preferences. Caregivers expressed concern for transfers, driving, fall prevention, home modifications, and wished for realistic information. Incorporating stroke survivors and their families' perspectives during rehabilitation may enhance patient-centered outcomes.

Objective: To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI)., Design: Prospective study., Setting: Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation., Participants: A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583)., Interventions: Inpatient rehabilitation., Main Outcomes Measures: Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument., Results: Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission., Conclusions: Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Caregivers usually are not involved while planning the stroke survivor's medical and rehabilitation goals and interventions. This review aimed to identify the needs of stroke survivors as perceived by their caregivers., Design: A literature search from 2003 to 2014 was conducted using Medline, CINAHL, PsychINFO, and Google Scholar. Sixty-six studies were included. Most studies excluded did not encompass caregivers' perspectives. Four reviewers screened the titles, abstracts, and full texts of the articles for inclusion. The data extracted from these studies were synthetized into metathemes., Results: Fifty-two qualitative, ten quantitative survey, and four mixed-methods studies were included in the final synthesis. The studies came from 11 countries. The data synthesis produced following three metathemes: (a) body functional needs, including psychological function, physical function, cognitive function, and uncertainty related to function; (b) activity and participatory needs, including healthy lifestyle, physical activities, speech, independence, cognitive activities, and uncertainty related to activities and participation; and (c) environmental needs, encompassing support, services, safety, accommodation and accessibility, and uncertainty related to environmental factors., Conclusions: This scoping review identified a range of needs of stroke survivors as perceived by their caregivers. Incorporating the caregiver's preferences and values into clinical decisions may improve outcomes among stroke survivors.

Objective: To evaluate the effectiveness of an educational intervention designed to reduce traumatic brain injury (TBI)-related misconceptions among blacks and Latinos with complicated mild to severe TBI., Design: Randomized controlled trial with masked 1-month follow-up., Setting: Community., Participants: Persons (N=52) with complicated mild to severe TBI (mean best day 1 Glasgow Coma Scale score, 11.27±3.89) were randomly recruited from 141 eligible participants (mean age, 37.71±13.88y; age range, 19-66y; mean months postinjury, 24.69±11.50); 25 participants (48.1%) of participants were black and 27 (51.9%) were Hispanic/Latino. Of the Hispanic/Latino participants, 18 (66.7%) were non-U.S. born and 12 (44.4%) spoke Spanish as their primary language. Twenty-seven individuals were randomized to the educational intervention group and 25 were randomized to the wait-list control group., Interventions: Single-session educational intervention with written materials provided in English or Spanish., Main Outcome Measures: Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire administered at baseline and 1-month follow-up., Results: After controlling for ethnic and language differences, a significant between-group main effect (P=.010) and a significant time-group interaction for the Common Misconceptions about Traumatic Brain Injury Questionnaire were noted (Wilks Λ=.89; F 1,46 =6.00; P=.02). The intervention group showed a decrease in TBI misconception percentages, whereas the wait-list control group maintained similar percentages. At 1-month follow-up, the wait-list control group reported more misconceptions than did the intervention group (P=.019)., Conclusions: An educational intervention developed to address the recovery process, common symptoms, and ways to handle the symptoms provides promise as a tool to decrease TBI misconceptions among persons from ethnically and educationally diverse backgrounds. The effects of therapist characteristics and the client-therapist relation on outcomes should be further explored., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate sexual functioning and its predictors in spouses/partners of persons with traumatic brain injury (TBI)., Design: Inception cohort survey., Setting: Community., Participants: Persons (N=70) with complicated mild to severe TBI admitted to 1 of 6 participating TBI Model Systems inpatient rehabilitation units and their spouses/partners who were both living in the community and assessed 1 year after injury., Interventions: Not applicable., Main Outcome Measures: Derogatis Interview for Sexual Functioning Self-Report; Global Sexual Satisfaction Index., Results: Twenty percent of spouses/partners of persons with TBI reported sexual dysfunction, and 44% reported dissatisfaction with sexual functioning. Sixty-two percent of spouses/partners reported a decrease in sexual activity during the year postinjury, 34% reported a decrease in sexual drive or desire, and 34% indicated that sexuality was less important in comparison to preinjury. The sexual functioning of spouses/partners of persons with TBI was highly associated with the sexual functioning of the person with TBI. Age of spouses/partners and sexual functioning in persons with the TBI were significant predictors of spouses'/partners' sexual functioning, even after controlling for sex of partners and the physical, cognitive, participation, and sexual functioning of the persons with injury., Conclusions: Greater sexual dysfunction in spouses/partners was associated with older age and with poorer sexual functioning in the person with injury. Rehabilitation professionals should provide education on the potential impact of TBI on sexual functioning for both persons with TBI and their spouses/partners, and integrate the assessment of sexual functioning into their clinical assessment, making appropriate referrals for therapy., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigates the contribution of pre-injury family functioning and resources on self-reported post-concussive symptoms and functional outcomes in persons with mild TBI (mTBI)., Design: Participants with uncomplicated or complicated mTBIs were recruited from consecutive admissions to the emergency department of a level 1 trauma centre. Patients completed baseline assessments within 2 weeks of injury and an outcomes assessment at 3 months post-injury., Methods and Procedures: One hundred and sixty-six adults with mTBI were included. Baseline measures of pre-injury history, family functioning and resources were obtained. Functional status assessments and self-reported measures of health, common TBI symptoms and psychological problems were administered at 3-months post-injury., Results: Data reduction of outcome measures using principle components analysis revealed two factors: self-reported post-concussive symptoms and current functional/participation status, explaining 60.53% of the variance. Family resources (β = -0.239, t(150) = -2.84, p = 0.005) and age (β = -0.170, t(150) = -2.19, p = 0.030), but not family functioning, were significant predictors of self-reported post-concussive symptoms at follow-up, R 2 = 0.051, F(5, 150) = 4.09, p = 0.002. Neither family resources nor functioning predicted current functional/participation status., Conclusions: Fewer family resources and younger age were associated with increased self-reported post-concussive symptoms. Fewer resources may be a potential risk factor to heightened perception of post-concussive symptoms. Providing low-cost counselling or resource facilitation services may improve outcomes for those with limited resources after mTBI.

Objective: To examine the factor structure and construct validity of the Community Integration Questionnaire, a widely used measure of community participation among individuals with traumatic brain injury (TBI), among 3 racial/ethnic groups., Design: Prospective longitudinal cohort study., Setting: Enrollment in acute inpatient TBI rehabilitation with follow-up at 1 year after injury., Participants: A total of 1756 persons with TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) national Database., Main Outcome Measure: Community Integration Questionnaire at 1 year after injury., Results: The goodness of fit for the factor structure of the Community Integration Questionnaire, separating items into Home Competency, Social Integration, and Productive Activity, was satisfactory for whites but not for blacks or Hispanics., Conclusions: Clinicians and researchers should take race/ethnicity into account when utilizing measures of community integration.

Objective: To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI)., Design: Prospective cohort study., Setting: Community., Participants: A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community., Main Measures: Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9., Results: Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23-5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression., Conclusions and Implications: Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

Objective: To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals., Design: Prospective cohort study., Setting: Community., Participants: Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community., Interventions: None., Main Outcome Measures: Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals., Results: Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all., Conclusions: Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate common TBI misconceptions among ethnic minorities with TBI., Design: Cross-sectional study., Setting: Level I trauma center., Participants: Fifty-eight persons with TBI (28 black and 30 Hispanic) discharged from the neurosurgery unit and living in the community., Main Measure: Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire (CM-TBI)., Results: Participants displayed misconceptions about approximately one-third of the 40 items, most regarding amnesia and recovery. Fewer misconceptions were found in the brain damage/injury and sequelae categories. A greater percentage of TBI misconceptions was associated with having lower education, actively practicing religion, being Spanish-speaking and non-US born. After controlling for education and actively practicing religion, Spanish-speaking Hispanics reported a greater percentage of misconceptions than English-speaking Hispanics and blacks., Conclusions and Implications: Understanding common TBI misconceptions can assist rehabilitation staff in tailoring education programs for racial/ethnic minorities including those who are Spanish-speaking. Educational attainment and cultural factors should be considered when developing educational interventions for persons with TBI from diverse backgrounds. Inaccurate information regarding TBI, especially the recovery process, may hinder treatment planning by rehabilitation professionals and may result in disappointment and the setting of unrealistic goals for persons with injury and their families.

Objective: To investigate the meaning of community integration in an ethnically diverse sample., Design: Prospective study using mixed qualitative and quantitative methods., Setting: County level I trauma center., Participants: Fifty-eight blacks, 57 Hispanics, and 52 whites with traumatic brain injury living in the community 6 months postinjury., Main Measures: Open-ended interview questions and a questionnaire assessing perceived importance of community integration activities., Results: Resulting themes indicated that feeling part of the community was related to type and quality of community relationships, perceived safety and security, active involvement, feeling included and respected, and familiarity with the community. Themes regarding barriers included the following: environmental and social barriers; injury-related cognitive and physical changes; dissimilarities to others; relocation; and financial issues. Blacks and Hispanics placed more emphasis on domestic activities than did whites., Conclusions and Implications: Feeling integrated into the community relates to aspects of the environment as much as to involvement in specific activities. Environmental barriers can be just as important as injury-related changes. Different racial/ethnic groups place different value on participation activities. The results emphasize the importance of assessing subjective aspects of community integration, individualizing rehabilitation goals, and intervening in the environment to facilitate participation.

Objective: To evaluate the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for persons with traumatic brain injury (TBI)., Design: Prospective cohort study., Participants: A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care or inpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 months postinjury)., Measures: La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig Handicap Assessment and Reporting Technique-Short Form Social Integration subscale (CHART-SF-SI), Community Integration Questionnaire Social Integration subscale (CIQ-SI)., Results: Social communication measures (LCQ, AIPSS) and self-reported behavioral functioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographic and injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioral variables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI., Conclusions: Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.