National Data and Statistical Center

JFK-Johnson Rehabilitation Institute Traumatic Brain Injury Model System

Johnson Rehabilitation Institute strives to integrate the highest quality of clinical and research activities within an integrated model system of care, to improve the lives of people with traumatic brain injury. Our clinical continuum of care includes two Level I Trauma Centers, two Level Two Trauma Centers and two emergency departments; the acute Brain Trauma Unit and inpatient Extended Recovery Unit; Transitional Living; comprehensive post-acute Neurorehabilitation and an Intensive Cognitive Rehabilitation Program; and long-term follow-up and aftercare services. We project enrolling 40 TBIMS participants and conducting 118 follow-up interviews annually. Our site-specific research represents a sustained investigation of cerebral activation in patients with disorders of consciousness (DOC): vegetative state (VS) and minimally conscious state (MCS). At present, clinical judgment and experience guide diagnostic, prognostic and treatment decisions for individuals with DOC. However, we continue to struggle with diagnostic error, misinterpretation of behavioral findings, inability to predict functional outcome in individual cases, and uncertainty regarding the neural mechanisms of recovery. When combined with behavioral observations, functional neuroimaging strategies have the potential to improve clinical decision-making and patient care. Our prior research on fMRI activation patterns suggests that patients in MCS retain the neural circuits for receptive language and visual processing. We will test a novel fMRI protocol that is designed to reliably detect conscious awareness in patients who may be unable to execute behavioral signs of active cognitive processing, using a hierarchical stimulation paradigm that systematically assesses levels of cognitive processing in the auditory and visual systems. In light of provocative findings suggesting that cognitive processing may be maintained in patients who appear to be unconscious on bedside examination, we will extend our investigation to individuals with VS as well as those in MCS. We also predict that patients capable of activating multiple cortical networks will achieve more favorable cognitive and functional outcomes, a finding with direct implications for rehabilitation treatment planning. Our second project extends our prior investigations of the effectiveness of specialized, post-acute brain injury rehabilitation. This project is driven by the question of how to characterize the course of post-acute brain injury rehabilitation, and its impact on the long term outcomes of people with brain injuries. Although there is increasing evidence that postacute brain injury rehabilitation can improve functional outcomes after TBI, population-based outcome studies have generally not considered the influence of different pathways of postacute rehabilitation on outcomes after TBI. We are proposing a longitudinal, observational study that will characterize postacute rehabilitation in the TBI Model Systems, and examine the pathways of postacute rehabilitation in relation to case-mix variables, patterns of service utilization, barriers to service delivery, and participants’ perceived needs and satisfaction with treatment. We will examine the contribution of postacute rehabilitation to functional and psychosocial outcomes at one and two years after injury using multivariate analyses and causal modeling. Our dissemination plan addresses the needs of clinicians, researchers, people with TBI and their families. These research and dissemination efforts should benefit people with disabilities through increased knowledge of functional level and prognosis for patients with DOC, increased knowledge of factors influencing access to postacute services and the impact of postacute rehabilitation on outcomes, and the application of evidence-based rehabilitation interventions after TBI.