Early cognitive status and productivity outcome after traumatic brain injury: Findings from the TBI Model Systems

doi:10.1053/apmr.2002.28802

Archives of Physical Medicine and Rehabilitation

Volume 83, Issue 2, February 2002, Pages 183-192

https://doi.org/10.1053/apmr.2002.28802 Get rights and content

Abstract

Sherer M, Sander AM, Nick TG, High WM Jr, Malec JF, Rosenthal M. Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI Model Systems. Arch Phys Med Rehabil 2002;83:183-92. Objective: To evaluate the contribution of early cognitive assessment to the prediction of productivity outcome after traumatic brain injury (TBI) adjusted for severity of injury, demographic factors, and preinjury employment status. Design: Inception cohort. Setting: Six inpatient brain injury rehabilitation programs. Participants: A total of 388 adults with TBI whose posttraumatic amnesia (PTA) resolved before discharge from inpatient rehabilitation. Interventions: Administered neuropsychologic tests during inpatient stay on emergence from PTA. Follow-up interview and evaluation. Predictor measures also determined. Main Outcome Measure: Productivity status at follow-up 12 months postinjury. Results: Multiple logistic regression analysis revealed that preinjury productivity status, duration of PTA, education level, and early cognitive status each made significant, independent contributions to the prediction of productivity status at follow-up. When adjusted for all other predictors, persons scoring at the 75th percentile on early cognitive status (less impaired) had 1.61 times greater odds (95% confidence interval [CI], 1.07-2.41) of being productive follow-up than those scoring at the 25th percentile (more impaired). Without adjustment, persons scoring at the 75th percentile had 2.46 times greater odds (95% CI, 1.77-3.43) of being productive at follow-up. Conclusions: Findings support the utility of early cognitive assessment by using neuropsychologic tests. In addition to other benefits, early cognitive assessment makes an independent contribution to prediction of late outcome. Findings support the clinical practice of performing initial neuropsychologic evaluations after resolution of PTA. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Participants

All participants sustained a medically documented TBI and were enrolled in the Model Systems Research and Demonstration Project, a multicenter study of outcome after TBI, funded by the National Institute on Disability and Rehabilitation Research. Inclusion criteria for the TBI Model Systems Project include (1) at least 16 years of age at time of injury, (2) arrived at a TBI Model Systems level I trauma center within 24 hours of injury, (3) received both acute care and inpatient rehabilitation

Missing values

As noted earlier, subjects with missing 1-year postinjury outcome data were excluded from the study. Some subjects also had missing values for predictor variables. The percentage and frequency of missing values for neuropsychologic test scores are presented in table 3.

. Percentage (frequency) missing and quartiles for neuropsychologic test scores (N = 388)

Test	% (n) Missing	Median (25th, 75th percentile)
Token Test	15 (59)	41 (37, 43)
COWAT	14 (53)	23 (18, 31)
VFDT	10 (39)	28 (24, 31)
BDT	18 (69)	17 (11, 24)
GPT

Discussion

Findings of our investigation provide strong support for the use of early cognitive assessment in predicting late functional outcome after TBI. The median time from injury to assessment was 28 days, and yet the findings were predictive of productivity outcome assessed 1-year postinjury. The positive predictive power of early cognitive assessment was significant even when adjusted for other significant predictors of outcome such as severity of injury (duration of PTA), preinjury education level,

Conclusions

There are some limitations to the generalization of findings from our study. Subjects studied were those patients with TBI who required inpatient rehabilitation and whose PTA resolved during their inpatient stay. This population is more severely impaired than the overall population of persons who sustain TBI. Our subjects were recruited at 6 inpatient rehabilitation centers, each of which is subject to local referral patterns and standards of care. Although subject accrual at any 1 site was

Acknowledgements

Data for subjects reported on in this study were contributed by the TBI Model Systems programs at Santa Clara Valley Medical Center, San Jose, CA; Rehabilitation Institute of Michigan, Detroit, MI; Ohio State University, Columbus, OH; Moss Rehabilitation Research Institute, Philadelphia, PA; The Institute for Rehabilitation and Research, Houston, TX; and Virginia Commonwealth University/Medical College of Virginia, Richmond, VA.

References (63)

DX Cifu et al.
Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis
Arch Phys Med Rehabil
(1997)
C Boake et al.
Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury
Arch Phys Med Rehabil
(2001)
B Jennett et al.
Assessment of outcome after severe brain damage
Lancet
(1975)
HA Rusk et al.
Rehabilitation of the brain-injured patient
Med Clin North Am
(1969)
LJ Horn et al.
Rehabilitation of traumatic brain injury
N Brooks et al.
The five year outcome of severe blunt head injury: a relative's view
J Neurol Neurosurg Psychiatry
(1986)
B Jennett et al.
Disability after severe head injury: observations on the use of the Glasgow Outcome Scale
J Neurol Neurosurg Psychiatry
(1981)
HS Levin
Neurobehavioral sequelae of closed head injury
M Sherer et al.
Outcome after moderate and severe closed head injury: a review and introduction to life care planning
J Head Trauma Rehabil
(2000)
SS Dikmen et al.
Employment following traumatic head injuries
Arch Neurol
(1994)

JH Ellenberg et al.

Posttraumatic amnesia as a predictor of outcome after severe closed head injury

Arch Neurol

(1996)

American Academy of Neurology

Assessment: neuropsychological testing of adults. Considerations for neurologists

Neurology

(1996)

HS Levin

A guide to clinical neuropsychological testing

Arch Neurol

(1994)

F Crépeau et al.

Predictors and indicators of work status after traumatic brain injury: a meta-analysis

Neuropsychol Rehabil

(1993)

JD Bayless et al.

Tinker toy test performance and vocational outcome in patients with closed-head injuries

J Clin Exp Neuropsychol

(1989)

N Brooks et al.

Return to work within the first seven years of severe head injury

Brain Inj

(1987)

RE Hanlon et al.

Effects of acute injury characteristics on neurophysical status and vocational outcome following mild traumatic brain injury

Brain Inj

(1999)

S Melamed et al.

Attention capacity limitation, psychiatric parameters and their impact on work involvement following brain injury

Scand J Rehabil Med

(1985)

R Weddell et al.

Social adjustment after rehabilitation: a two year follow-up of patients with severe head injury

Psychol Med

(1980)

O Ezrachi et al.

Predicting employment in traumatic brain injury following neuropsychological rehabilitation

J Head Trauma Rehabil

(1991)

CS Lam et al.

Neuropsychological indicators of employability following traumatic brain injury

Rehabil Counseling Bull

(1991)

RM Ruff et al.

Predictors of outcome following severe head trauma: follow-up data from the Traumatic Coma Data Bank

Brain Inj

(1993)

TV Ryan et al.

Utilizing neuropsychological measures to predict vocational outcome in a head trauma population

Brain Inj

(1992)

WH Burke et al.

Comprehensive head injury rehabilitation: an outcome evaluation

Brain Inj

(1988)

JF Malec et al.

Outcome evaluation and prediction in a comprehensive-integrated post-acute outpatient brain injury rehabilitation programme

Brain Inj

(1993)

GP Prigatano et al.

Neuropsychological rehabilitation after closed head injury in young adults

J Neurol Neurosurg Psychiatry

(1984)

R Fraser et al.

Employability of head injury survivors: first year post-injury

Rehabil Counseling Bull

(1988)

J Vilkki et al.

Prediction of psychosocial recovery after head injury with cognitive tests and neurobehavioral ratings

J Clin Exp Neuropsychol

(1994)

RJ Fabiano et al.

Variables associated with employment following severe traumatic brain injury

Rehabil Psychol

(1995)

J Fleming et al.

Prediction of community integration and vocational outcome 2-5 years after traumatic brain injury rehabilitation in Australia

Brain Inj

(1999)

T Najenson et al.

Rehabilitation outcome of brain damaged patients after severe head injury

Int Rehabil Med

(1980)

Cited by (150)

Predictive Value of a New Brief Cognitive Test for Long-term Functional Outcome in Acute Traumatic Brain Injury
2022, Archives of Physical Medicine and Rehabilitation
To determine how results on the EXAmen Cognitif abrégé en Traumatologie (EXACT), a new test specifically designed to briefly assess global cognitive functioning during the acute phase of traumatic brain injury (TBI), can predict long-term functional outcome compared with length of posttraumatic amnesia (PTA), a well-established predictor.
Inception cohort.
Level 1 trauma center.
A total of 90 patients (N=90) hospitalized for a moderate or severe TBI.
Not applicable.
Performance on the EXACT in the first 3 months after injury and results on the Disability Rating Scale (DRS) at follow-up 1-2 years later.
EXACT scores were all correlated with length of PTA and DRS result. Compared with length of PTA, the EXACT added significantly to the regression and improved prediction of functional outcome. More specifically, a total score ≤80 on the EXACT was associated with a higher rate of long-term disability because of more severe TBI consequences. Behavioral regulation and executive functions were the cognitive domains that showed the most impairment, followed by attention and working memory as well as episodic memory. Except for length of PTA and hospital stay, the DRS score was not correlated with other demographic (age, education) or clinical variables (Glasgow Coma Scale and maximum score on the Therapy Intensity Level Scale).
The EXACT can be administered to most patients early in the acute phase of TBI, and results could be used, along with other predictors such as PTA, to estimate their long-term functional sequelae. The EXACT may be a promising brief cognitive instrument for future studies investigating recovery after TBI.
Psychological Assessment and Intervention in Rehabilitation
2018, Braddom's Rehabilitation Care: A Clinical Handbook
With regard to assessment, one of the core competencies of a psychologist working in rehabilitation is the capability to select and interpret psychometric tests and measures. Psychologists collect information to predict outcomes, identify facilitators and barriers, and measure community participation and quality of life in the acute, inpatient, and postacute phases of an injury. Cognitive assessment and modification of the environment for awareness impairment can reduce the risk of inpatient injury. Compensatory and metacognitive strategies to improve generalization to real-world activities for attention impairment are recommended. Patients with mild to moderate memory impairment can be trained in the use of internal and external compensatory strategies, whereas patients with more severe memory impairment should use external memory strategies. Cognitive behavioral therapies (CBTs) for emotional impairment are effective for people with intact cognition, whereas supportive psychotherapy may be more appropriate for people with severe cognitive deficits. Manipulation of the antecedents can prevent problem behavior from occurring, and contingency management can increase or decrease specific behaviors.
Cognitive Rehabilitation Following Traumatic Brain Injury: A Survey of Current Practice in Australia
2019, Brain Impairment
Emotional, Behavioral, and Cognitive Symptom Associations with Community Participation in Chronic Traumatic Brain Injury
2024, Journal of Head Trauma Rehabilitation
Longitudinal recovery of executive functions and social participation prediction following traumatic brain injury
2024, Applied Neuropsychology:Adult
Understanding and managing the long-term cognitive consequences of traumatic brain injuries
2023, British Journal of Hospital Medicine

View all citing articles on Scopus

^☆: Supported by the National Institute on Disability and Rehabilitation Research.

^☆☆: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

^★: Reprint requests to Mark Sherer, PhD, ABPP/Cn, Methodist Rehabilitation Center, 1350 E Woodrow Wilson, Jackson, MS 39216, e-mail: [email protected].

^★★: Supplier

^♢: a. Insightful Corp, 1700 Westlake Ave N, Ste 500, Seattle, WA 98109.

View full text

ArticlesEarly cognitive status and productivity outcome after traumatic brain injury: Findings from the TBI Model Systems☆,☆☆,★,★★,♢

Abstract

Section snippets

Participants

Missing values

Discussion

Conclusions

Acknowledgements

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Lancet

Med Clin North Am

Rehabilitation of traumatic brain injury

The five year outcome of severe blunt head injury: a relative's view

J Neurol Neurosurg Psychiatry

Disability after severe head injury: observations on the use of the Glasgow Outcome Scale

J Neurol Neurosurg Psychiatry

Neurobehavioral sequelae of closed head injury

Outcome after moderate and severe closed head injury: a review and introduction to life care planning

J Head Trauma Rehabil

Employment following traumatic head injuries

Arch Neurol

Posttraumatic amnesia as a predictor of outcome after severe closed head injury

Arch Neurol

Assessment: neuropsychological testing of adults. Considerations for neurologists

Neurology

A guide to clinical neuropsychological testing

Arch Neurol

Predictors and indicators of work status after traumatic brain injury: a meta-analysis

Neuropsychol Rehabil

Tinker toy test performance and vocational outcome in patients with closed-head injuries

J Clin Exp Neuropsychol

Return to work within the first seven years of severe head injury

Brain Inj

Effects of acute injury characteristics on neurophysical status and vocational outcome following mild traumatic brain injury

Brain Inj

Attention capacity limitation, psychiatric parameters and their impact on work involvement following brain injury

Scand J Rehabil Med

Social adjustment after rehabilitation: a two year follow-up of patients with severe head injury

Psychol Med

Predicting employment in traumatic brain injury following neuropsychological rehabilitation

J Head Trauma Rehabil

Neuropsychological indicators of employability following traumatic brain injury

Rehabil Counseling Bull

Predictors of outcome following severe head trauma: follow-up data from the Traumatic Coma Data Bank

Brain Inj

Utilizing neuropsychological measures to predict vocational outcome in a head trauma population

Brain Inj

Comprehensive head injury rehabilitation: an outcome evaluation

Brain Inj

Outcome evaluation and prediction in a comprehensive-integrated post-acute outpatient brain injury rehabilitation programme

Brain Inj

Neuropsychological rehabilitation after closed head injury in young adults

J Neurol Neurosurg Psychiatry

Employability of head injury survivors: first year post-injury

Rehabil Counseling Bull

Prediction of psychosocial recovery after head injury with cognitive tests and neurobehavioral ratings

J Clin Exp Neuropsychol

Variables associated with employment following severe traumatic brain injury

Rehabil Psychol

Prediction of community integration and vocational outcome 2-5 years after traumatic brain injury rehabilitation in Australia

Brain Inj

Rehabilitation outcome of brain damaged patients after severe head injury

Int Rehabil Med

Articles
Early cognitive status and productivity outcome after traumatic brain injury: Findings from the TBI Model Systems☆,☆☆,★,★★,♢