Multi-Site Telephone Intervention Study

The University of Washington is the lead center in an innovative, three-site TBI telephone intervention funded by the National Institute on Disability and Rehabilitation Research. The study is being carried out here as well as at two other Model Systems Centers across the country: Moss Rehabilitation Research Institute in Philadelphia, Pennsylvania and Methodist Rehabilitation, in Jackson, Mississippi.

The aim of the study is to evaluate the effect of a low-cost phone intervention for persons with moderate to severe TBI in such areas as community integration and employment at one and two years after injury. Participation in the study will be offered to individuals with TBIs who are receiving inpatient rehabilitation services at Harborview and the UW Medical Centers. The hope is to refine a model of service delivery that would be cost-effective, simple to replicate in a variety of settings, and effective in meeting the needs of those with less access to traditional community rehabilitation services.

The study was modeled after a successful pilot project carried out at the UW between 1998-2002. The pilot found that those who received the phone intervention had better outcomes of overall function and quality of life. The current project expands the number of subjects and the length of the intervention. Involving three separate sites that differ widely in regional location will also allow the investigators to evaluate whether the effects of the interventions are similar in different geographical areas and demographic subgroups.

Persons in the treatment group, along with a significant other, will receive phone calls from a Research Care Manager (RCM) periodically for 21 months. The RCM will provide supportive counseling, educational information about TBI, problem-solving assistance and referral to community resources. The intervention focuses on helping individuals increase their success at dealing with the multiple, complex challenges experienced after a TBI.

Post-Placement Vocational Treatment Services for Brain Injury

Sometimes people with traumatic brain injury (TBI) find it hard to get and keep a job. Although job coaching and vocational rehabilitation may help people with TBI, these services are not always available. The effectiveness of job coaching has never been tested in a controlled study.

In this project the University of Washington will be working with six other centers around the country, all collecting the same information about people who have a brain injury and who are receiving vocational services, and who have a job placement.  We will collect information about people who are working after a TBI, the services they receive, and whether they keep their jobs and are satisfied with their jobs for the first 6 months after being hired.

The researchers doing this study want to examine the different services and techniques used by rehabilitation hospitals to provide assistance to people with TBI in keeping a job.  Specifically they want:

The Natural History of Headache after TBI

Doctors and researchers know surprisingly little about headache after TBI even though it is the most common source of pain.  Most of the information has come from studies of people who come to clinics after mild TBI complaining of chronic headache.  These previous studies show that somewhere between 30 and 80% of persons with TBI have headaches.  However, it is important to note that many people who never had a TBI also have headaches.  We don’t fully understand if headaches after TBI are different from other headaches or whether people who had headaches before a TBI have different experiences from others.  Do some headaches start right away after injury and some after a delay?  Do headaches have any effect on the ability to return to previous activities and work?

The University of Washington is the primary site for a multi-center study looking at the natural history of headache after TBI.  Joining us are researchers from Mayo Clinic, University of Alabama, Medical College of Virginia, Moss Rehabilitation Hospital, University of Texas San Antonio, and Craig Hospital.  We are interviewing people still in the hospital after a TBI and then again at 3 month, 6 months, and one year after their injury.  Our goals are to: 1). To improve the health and well-being of persons with TBI by describing headaches, 2) To lay the groundwork for future research on pain and headache management.  To accomplish these goals, we will 1) measure how often headache occurs, 2) describe headaches after TBI, 3) identify what predicts headaches,  4) examine whether different traits predict acute and chronic types of headache, 5) measure the effect of headache on activities, community participation, and employment, and 6) assess the types of treatments offered and their effectiveness.

Modular Scheduled Telephone Intervention for Caregivers of Persons with Traumatic Brain Injury: A Randomized Controlled Trial

In this study, we propose to conduct a randomized controlled trial to test the efficacy of a client- and community-centered intervention for caregivers of persons with traumatic brain injury (TBI) consisting of education and mentoring in solving caregiver and brain injury related problems affecting everyday life. The intervention will begin with a face-to-face introductory orientation and training session between a trained Research Care Mentor (RCM) and the designated caregiver prior to the TBI survivor’s discharge from the acute rehabilitation unit. During the first five months following rehabilitation discharge, the RCM will initiate an additional 7 to 10 contacts with the caregiver by telephone on a bi-weekly basis. Each telephone contact will include (a) instruction from one of a series of educational modules; (b) identification of current problems, concerns, and goals; (c) mentoring in the generation of potential solutions or strategies for those problems; and (d) evaluation of the effectiveness of previous action steps. Referral for services will be provided as needed. Support and consultation will be provided to the RCM during this process by a team of experienced rehabilitation clinicians including medicine, nursing, psychology, occupational therapy, vocational rehabilitation, and social work. 

At 6 months following rehabilitation discharge, we will compare quality of life (QOL) and emotional well-being for caregivers receiving the telephone intervention and caregivers receiving standard care. In addition, we will examine the social significance of the intervention (i.e., caregiver participation in the community, caregiver employment, and use of resources); the social validity of the intervention from the caregiver perspective (e.g., helpfulness and accessibility); and the effect of the intervention on caregiver knowledge and self-efficacy. While the primary focus of the proposed study is on caregivers, we will also investigate differences in QOL and emotional well-being for the TBI survivors based on caregiver group assignment. In order to examine the maintenance of intervention effects over time, similar outcome assessments will take place at 6 months after discharge from the hospital and 1 year following the date of injury.

If this intervention is successful, it will improve the lives of caregivers and their effectiveness in providing care to individuals with TBI and, in turn, positively impact the lives of TBI survivors. There is marked variation in the long-term needs of people with TBI and their families depending on such factors as severity of injury, the pre-injury characteristics of the injured person, and the family/community in which that person lives. However, for most people with TBI, the cognitive, behavioral, and/or physical sequelae of TBI result in the need for assistance, supervision, or other forms of care giving for months or years after the injury.

The GeoID Study: Enhancing the TBI Model Systems Core Dataset to Expand Research on Environmental Influences Affecting Outcomes from TBI

Both theory and research support the idea that functional independence, social participation, productivity and life satisfaction after a TBI are in part due to the physical, economic, social or other characteristics of one’s immediate neighborhood or larger community. The proliferation of geographic databases containing information about societal factors presents an important opportunity for studying the role of neighborhoods and communities as environmental influences on functioning and disability.  This study, also being conducted at 7 other TBI Model System sites, has several goals.

1) To evaluate the feasibility, reliability and utility of recording geographic identifiers for place of residence of individuals enrolled in the TBI Model System at yearly follow-ups.

2) To determine the cost of recording state, county, census tract, block group and block for place of residence at each follow-up.

3) To determine the reliability of recordings made of state, county, census tract, block group and block.

4) To determine the utility of having state, county, census tract, block group and block at follow-up by conducting at least two multi-center studies using data from the U.S. decennial census. 

Prediction of Outcome Study

The overall aim of this project is to develop user friendly, methodologically high quality models for prediction of a number of important outcomes following TBI.  These outcomes will include neuropsychological status, functional status (including employment), emotional functioning, perceived quality of life, and post-traumatic symptoms. Prediction of outcome in individual cases is important for a number of reasons. Clinicians make diagnostic and therapeutic decisions based on prognosis. Prediction of outcome allows one to identify and provide appropriate treatment to those who need it. Prognostic information is also critical in counseling patients and their families to help them plan for the future. The importance of early identification of those who are likely to encounter long term limitations in their everyday life and the need to plan for care can not be over emphasized. While services for persons with TBI have always been limited, the situation has worsened since the introduction of the prospective payment system. Also challenging the system are the new cohort of injured soldiers returning from conflicts, whose futures depend on accurate functional prediction and diagnosis.

We expect that this proposed project will yield evidence-based, high quality, practical, and useful predictions of future expected outcomes.  Major benefits of such information are:

1. Clinicians can identify patients who are likely to have difficulties and thus refer or provide them with services aimed at preventing or reducing the magnitude of disabilities. Therefore the results have implications for changing clinical practice in a way that can improve quality of life of the survivors.

2. Resources can be more efficiently used. Survivors and their families can weigh expected outcomes in the context of available funds and how their available funds may be best used.

3. Performance of service providers can be examined against expected evidence-based data. Additionally, potential outcomes promised by providers’ services may be reviewed or even negotiated against such benchmark data. Today, in post acute TBI services at least, there is no data-driven matrix for making service decisions

4. Researchers can use such information in designing and/or analyzing observational rehabilitation treatment studies.  The predictions to be provided will allow forming groups with similar prognosis that can be fairly compared or accounting for differences in the analysis

5. Researchers can use such information in the design and analysis of future randomized studies of intervention, including choice of measures depending on the nature of the intervention planned and allowing for better stratification and data analysis, thus decreasing sample size needed or increasing power of the study.

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