Angelle M. Sander

Background: Trends in functional recovery after ischemic stroke within inpatient rehabilitation settings are not well‐described. This study evaluated 18‐year trends in functional motor improvement among adults receiving inpatient rehabilitation for ischemic stroke. Methods: We conducted a retrospective cohort study of adults with ischemic stroke admitted to a large rehabilitation system from December 2001 to September 2019. The primary outcome was the attainment of a minimal clinically important difference (MCID) in the Functional Independence Measure Motor score, defined as a ≥20‐point increase in Functional Independence Measure Motor score. Multivariable logistic regression was used to evaluate temporal trends and their interaction with insurance. Sensitivity analyses evaluated changes in case‐mix index, Charlson Comorbidity Index, and length of stay. Results: Among 9809 ischemic stroke rehabilitation admissions representing 9126 unique patients, 4445 (45.3%) admissions attained MCID. The adjusted odds of MCID attainment increased annually (odds ratio, 1.085 [95% CI, 1.067–1.104]). Model‐based predicted probabilities for MCID attainment increased from 0.239 (95% CI, 0.192–0.286) in 2001 to 0.555 (95% CI, 0.509–0.601) in 2019 for Medicare Fee‐for‐Service and from 0.345 (95% CI, 0.307–0.383) to 0.564 (95% CI, 0.530–0.598) for non‐Medicare patients. The year‐by‐insurance interaction was significant, indicating smaller annual gains for non‐Medicare patients (odds ratio, 0.973 [95% CI, 0.953–0.993]; P =0.007). The case‐mix index showed no temporal change, while the Charlson Comorbidity Index increased and length of stay declined over time. However, neither the Charlson Comorbidity Index, case‐mix index, nor rehabilitation duration explains the temporal improvement in MCID attainment. Conclusions: Functional motor recovery improved substantially over 18 years, independent of patient complexity and comorbidity burden, establishing contemporary benchmarks for inpatient stroke rehabilitation outcomes.

Objective: To investigate impairment rates on the Brief Test of Adult Cognition by Telephone (BTACT) domains and subtests by race/ethnicity, education, and primary language for individuals with moderate-to-severe traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems (TBIMS) national database. Setting: Secondary analysis of the TBIMS national database. Participants: A total of 2,981 adults with complicated-mild-to-severe TBI who completed all BTACT subtests at 1-year follow-up ( M _age = 41.0 years; 27.1% Female; M _education = 13.6 years; 63.5% White). Design: Cross-sectional observational study. Main Measures: Brief Test of Adult Cognition by Telephone domain and subtest scores were standardized using combined Midlife Development in the US norms. Cognitive impairment was defined as scores ≤ −1.5 below the normative means. Impairment rates were compared across race/ethnicity, language of administration (Spanish versus English), and education. Logistic regression models evaluated the contribution of race/ethnicity, education, and language to impairment after controlling for variables that the normative data are stratified on (age, education, sex). Results: Participants who identified as Black, Hispanic, or multiracial were more likely to be classified as cognitively impaired on the BTACT domain scores and subtests. Individuals with ≤eighth grade education had higher impairment rates on recall and executive function measures. Spanish-language administration revealed increased odds of impairment on executive functioning tasks. Racial/ethnicity disparities in impairment persisted after adjustment for age, sex, and years of education. Conclusions: Findings indicate that BTACT normative data disproportionately classify those with lower education, racial/ethnic minority, and Spanish speakers as cognitively impaired. This can result in misinterpretation of disparities in cognitive outcomes and highlight the need for demographically representative normative data. Appropriate norms are critical for accurate assessment of cognitive outcomes and for the valid interpretation of the trajectories in diverse TBI populations.

Caregiving for individuals with traumatic brain injury (TBI) is often highly stressful, and traditional in-person interventions can be inaccessible given the demands of their caregiver role. Mobile health (mHealth) interventions offer a low-burden, scalable alternative by delivering personalized, real-time support. However, how effective these interventions depends on whether people perceive them as useful and engage with them. The role of perceived usability in mHealth efficacy remains underexplored in the TBI caregiver population. This study primarily evaluates the relationship between self-reported app usability and the efficacy of a fully automated mHealth intervention, delivered via personalized mobile-app messages, in reducing caregiver strain, anxiety, and depression in a TBI caregiver population. The secondary aim is to identify variables that moderate the intervention efficacy among caregivers reporting high app usability. We analyzed data from 122 TBI caregivers assigned to receive self-monitoring plus push notifications for self-care as part of a larger randomized controlled trial. Perceived app usability was assessed via caregiver responses to a questionnaire item. We applied multivariate linear models with a weighted and centered least squares estimator to assess the moderating effects of perceived app usability and other variables on message efficacy. Messages were more effective in reducing depression among TBI caregivers who reported high app usability. Moreover, shorter caregiving duration, higher Fitbit step count, and lower prior-week anxiety were significantly associated with improved message efficacy among this high usability group. Perceived app usability plays a critical role in the mHealth message efficacy among TBI caregivers. Tailoring interventions based on perceived app usability and identified moderators may optimize health outcomes and support more personalized care for this population. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Background: Behavioral interventions are effective for improving mental and physical health, but individuals with traumatic brain injury (TBI) often experience cognitive and behavioral impairments that limit their ability to engage with and benefit from standard treatments. Purpose: To describe practical adaptations to evidence-based behavioral interventions that enhance treatment receipt (comprehension and engagement) and enactment (application in daily life) for individuals living with TBI. Methods: We synthesized adaptation strategies derived from seven clinical trials targeting emotional functioning, problem-solving, and health behaviors in individuals with TBI. Adaptations were organized using a treatment fidelity framework distinguishing treatment receipt and enactment and informed by cognitive rehabilitation principles. Results: Adaptations to support treatment receipt included simplifying and contextualizing information, increasing repetition, using visual aids, and incorporating structured prompts to accommodate deficits in processing speed, attention, and memory. Process modifications included slower pacing, shorter or more frequent sessions, and integration of remote delivery with technology training and support. Adaptations targeting treatment enactment emphasized habit formation, repeated practice, external memory aids, and technology-based prompts to support prospective memory and initiation. Involvement of care partners and peers further enhanced engagement and generalization of skills. Conclusions: Systematic adaptations addressing cognitive and behavioral challenges can improve the accessibility and effectiveness of behavioral interventions for individuals with TBI. Further research should systematically document and evaluate treatment adaptations to determine which modifications are most strongly associated with improved treatment receipt, treatment enactment, implementation outcomes, and clinical benefit across differing cognitive and behavioral profiles.

Background: Health perceptions affect health behaviors, engagement with healthcare providers and treatments, and health outcomes. However, tools to evaluate patient health perceptions are lacking. Therefore, we developed the Multidimensional Health Perceptions Questionnaire (MHPQ) as a comprehensive but brief self-reported measure of an individual’s health perceptions, agnostic to condition. This type of instrument is needed to help evaluate the effect of health perceptions on health-related outcomes in addition to informing adaptation of care to improve patient provider interactions. In a prior study, the MHPQ demonstrated excellent content validity (content validity index=98.1%) and conceptual equivalence in English and Spanish in the general population, with a reading grade level of th grade in both languages. We found a 7-factor structure in the general population (combined English and Spanish speakers), but limitations in the representativeness of the sample warranted further investigation into the factor structure of the MHPQ.¹ Additionally, validation in unique populations – like traumatic brain injury (TBI) – is consistent with best practice. Objective: To determine the factor structure of the MHPQ among adults with >1 year history of traumatic brain injury (TBI) that required inpatient rehabilitation. Participants: Participants (n=250) enrolled in the TBI Model Systems National Database across five participating centers who completed a follow-up assessment between September 1^st, 2023 and June 19^th, 2024. All participants had experienced a TBI requiring inpatient rehabilitation and ranged from 1-35 years post-injury. All were able to complete a self-reported survey. Methods: We administered the original 65-item MHPQ as an electronic survey (REDCap™) or via telephone interview (if preferred) to participants. All items are rated on a 1=Strongly disagree to 5=Strongly agree response scale. Results: N=250 participants with a history of TBI completed the MHPQ in English. The sample was 30.8% CIS-female (68.4% CIS-male, 0.8% Other gender), 18-90 years old (M=45.8, SD=16.2), 16.0% Hispanic/Latino, and predominantly White (68.0%), followed by Black (18%), and all other races (2.0-5.2%). Exploratory Factor Analysis resulted in 53 final items with a multidimensional structure and good internal consistency reliabilities, with the following eight health perceptions domains (% variance, Cronbach’s α): Anticipated Discrimination and Judgement (10 items; α=.90); Communication with Healthcare providers (9 items; α=.79); Spiritual Health Beliefs (8 items, α=.88), Health Self-Efficacy (5 items, α=.73), Trust in Social Health Advice (5 items, α=.78), Trust in Medicine (6 items, α=.76), How Health Affects My Life (5 items, α=.71), and How Others Affect My Health (5 items, α=.64) Conclusions: Results suggest that the MHPQ could be a valid and reliable measure for comprehensively characterizing health perceptions among individuals who have experienced TBI. It demonstrated an 8-factor structure, with 8 distinct subscales each yielding average scores (1-5). Further validation through Rasch analysis and for the Spanish-language version of the MHPQ are forthcoming.

Objective: To explore and visually display differences in the distribution of the Glasgow Outcome Scale – Extended (GOS-E) over time after traumatic brain injury (TBI), focusing on variations in outcome distributions based on GOS-E at Year 1 postinjury and age at injury. Setting: Community. Participants: 14 010 individuals who received inpatient rehabilitation in the TBI Model Systems. Design: Cross-sectional analysis of a prospectively collected longitudinal database. Main Measures: GOS-E scores at 1, 2, 5, 10, 15, and 20 years postinjury, and age at injury. Results: The proportions of cases in each GOS-E category are displayed using 100% stacked bar graphs for each follow-up period. These graphs reveal that GOS-E at Year 1 and age at injury clearly influence outcomes over time. Trends include decreasing good recovery and increasing severe disability as Year 1 GOS-E worsens, along with rising mortality rates as age at injury increases. Conclusion: The study introduces a novel approach for visually representing patterns of change in GOS-E outcomes, emphasizing differences across strata defined by GOS-E at Year 1 and age at injury. The figures provide a valuable tool for communicating potential outcomes, particularly when GOS-E at Year 1 and age are known. Evaluating the visual interpretability of these graphs among persons with brain injury, family members, healthcare providers, and other stakeholders will help determine their broader usability and value.

Background: Compliance rates for mobile health (mHealth) studies that involve intensive study designs are highly variable. Both person- and study-specific factors likely contribute to this variability. We were interested in understanding the impact that care partner characteristics and demographics have on study engagement, given that engagement is critical to the success of mHealth interventions. Objective: The primary objective of this report was to analyze the overall and component-specific completion and compliance rates for an intensive 6-month mHealth intervention (CareQOL app) designed to promote self-awareness and self-care among care partners of individuals with traumatic brain injury. Methods: This randomized controlled trial was designed to test the CareQOL app, an mHealth app designed to promote care partner self-awareness (through self-monitoring) and self-care (through personalized self-care push notifications). The study design consisted of a baseline assessment, a 6-month home-monitoring period that included 3 daily ecological momentary assessment (EMA) questions, monthly patient-reported outcome (PRO) surveys, continuous activity and sleep monitoring using a Fitbit, and 2 follow-up PRO surveys at 3 and 6 months posthome monitoring. Three participants withdrew prior to the initiation of the home-monitoring period, resulting in a final analytical sample size of 254. All participants had access to a self-monitoring dashboard (CareQOL app) that included graphical displays of the daily survey scores, as well as daily steps and sleep data from the Fitbit. Results: Overall compliance for the different aspects of the study was high. On average, the full-sample daily EMA PRO completion rate was 84% (SD 19%), Fitbit-based step count compliance was 90% (SD 21%), and Fitbit-based sleep duration compliance was 75% (SD 32%); there was no difference between the study arms for daily EMA PROs and Fitbit compliance rates. Completion rates for monthly and follow-up PRO surveys were even higher, with average end-of-month completion rates ranging from 97% to 100%, and follow-up completion rates of 95% for both time points. Again, these rates did not differ by study arm. The data were represented by 3 engagement groups: high-compliance—all data; high-compliance—PROs and steps only; and moderate PRO compliance—low Fitbit compliance. Group membership was predicted by both race (P<.001) and relationship to the care recipient (P=.001), but not by the other person-specific variables. Conclusions: The compliance rates for this intensive study design are consistent, but at the high end, with what has been reported previously in the literature for studies with shorter time durations. Except for race and relationship to the care recipient, person-specific factors did not appear to be significantly associated with the engagement group. As such, we anticipate that the high compliance rates observed in this study are likely due to several study-specific design elements that were used to encourage study engagement.

Insurance is an important social determinant of health that can contribute to health inequities. Many patients with traumatic brain injury...